southeasthealth title xviii medicare cost report...title xviii title v part a part b hit title xix...

SoutheastHEALTH

Title XVIII Medicare Cost Report Provider CCN: 26-0110

Year Ended December 31, 2015

In Lieu of Form CMS-2552-10Health Financial Systems

FORM APPROVED

OMB NO. 0938-0050

This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim

payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).

Date/Time Prepared:

Worksheet S

Parts I-III

5/25/2016 12:15 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX COST REPORT CERTIFICATION

AND SETTLEMENT SUMMARY

PART I - COST REPORT STATUS

Provider

use only

[ X ]Electronically filed cost report Date:5/25/2016 Time: 12:15 pm

[ ]Manually submitted cost report

[ 0 ]If this is an amended report enter the number of times the provider resubmitted this cost report

Contractor

use only

[ 1 ]Cost Report Status

(1) As Submitted

(2) Settled without Audit

(3) Settled with Audit

(4) Reopened

(5) Amended

Date Received:

Contractor No.

NPR Date:

Medicare Utilization. Enter "F" for full or "L" for low.

Contractor's Vendor Code:

[ 0 ]If line 5, column 1 is 4: Enter

number of times reopened = 0-9.

[ N ]

4

Initial Report for this Provider CCN

Final Report for this Provider CCN[ N ]

1.

2.

3.

4.

5. 6.

7.

8.

9.

10.

11.

12.

[ F ]

PART II - CERTIFICATION

MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL, CIVIL AND

ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORT WERE

PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE ILLEGAL, CRIMINAL, CIVIL AND

ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.

CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)

I HEREBY CERTIFY that I have read the above certification statement and that I have examined the accompanying

electronically filed or manually submitted cost report and the Balance Sheet and Statement of Revenue and

Expenses prepared by SOUTHEAST MISSOURI HOSPITAL ( 260110 ) for the cost reporting period beginning 01/01/2015

and ending 12/31/2015 and to the best of my knowledge and belief, this report and statement are true, correct,

complete and prepared from the books and records of the provider in accordance with applicable instructions,

except as noted. I further certify that I am familiar with the laws and regulations regarding the provision of

health care services, and that the services identified in this cost report were provided in compliance with such

laws and regulations.

(Signed)

Officer or Administrator of Provider(s)

Title

Date

Encryption Information

ECR: Date: 5/25/2016 Time: 12:15 pm

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vNvFb00xCm39PZelOq1Mo4MyMdKxW0

JHOa2gqiYv0PG8BX

PI: Date: 5/25/2016 Time: 12:15 pm

g233kvzVR3M2ll.YAZ:x9pg2jWd6y0

dwmjD0ZOq0YwCIktLO2E5:olzOYud3

ABdU0ztzAA0dkLDI

Title XVIII

Title V Part A Part B HIT Title XIX

1.00 2.00 3.00 4.00 5.00

PART III - SETTLEMENT SUMMARY

1.00 Hospital 0 -127,491 -136,630 16,031 852,280 1.00

2.00 Subprovider - IPF 0 18,383 6 396,045 2.00

3.00 Subprovider - IRF 0 40,567 2 78,248 3.00

5.00 Swing bed - SNF 0 0 0 0 5.00

6.00 Swing bed - NF 0 0 6.00

9.00 HOME HEALTH AGENCY I 0 0 0 0 9.00

10.00 RURAL HEALTH CLINIC I 0 0 0 10.00

10.01 RURAL HEALTH CLINIC II 0 19,110 0 10.01

10.02 RURAL HEALTH CLINIC III 0 0 0 10.02

200.00 Total 0 -68,541 -117,512 16,031 1,326,573 200.00

The above amounts represent "due to" or "due from" the applicable program for the element of the above complex indicated.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0050. The time

required to complete and review the information collection is estimated 673 hours per response, including the time to review

instructions, search existing resources, gather the data needed, and complete and review the information collection. If you

have any comments concerning the accuracy of the time estimate(s) or suggestions for improving the form, please write to: CMS,

7500 Security Boulevard, Attn: PRA Report Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA

Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved

under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions

or concerns regarding where to submit your documents , please contact 1-800-MEDICARE.

SOUTHEAST MISSOURI HOSPITAL

MCRIF32 - 8.8.159.0 1 | Page


Date/Time Prepared:

Worksheet S-2

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX IDENTIFICATION DATA

1.00 2.00 3.00 4.00

Hospital and Hospital Health Care Complex Address:

1.00 Street:1701 LACEY STREET PO Box: 1.00

2.00 City: CAPE GIRARDEAU State: MO Zip Code: 63701 County: CAPE GIRARDEAU 2.00

Component Name

1.00

CCN

Number

2.00

CBSA

Number

3.00

Provider

Type

4.00

Date

Certified

5.00

Payment System (P,

T, O, or N)

V

6.00

XVIII

7.00

XIX

8.00

Hospital and Hospital-Based Component Identification:

3.00 Hospital SOUTHEAST MISSOURI

HOSPITAL

260110 16020 1 06/30/1966 N P O 3.00

4.00 Subprovider - IPF PSYCHIATRIC UNIT 26S110 16020 4 12/23/1992 N P O 4.00

5.00 Subprovider - IRF COMPREHENSIVE REHAB

UNIT

26T110 16020 5 01/01/2002 N P O 5.00

6.00 Subprovider - (Other) 6.00

7.00 Swing Beds - SNF 7.00

8.00 Swing Beds - NF 8.00

9.00 Hospital-Based SNF 9.00

10.00 Hospital-Based NF 10.00

11.00 Hospital-Based OLTC 11.00

12.00 Hospital-Based HHA SOUTHEAST MO HOSP REG

HOME HEALTH

267121 16020 06/30/1985 N P N 12.00

13.00 Separately Certified ASC 13.00

14.00 Hospital-Based Hospice SOUTHEAST HOSPICE 261537 16020 07/21/1993 14.00

15.00 Hospital-Based Health Clinic - RHC 15.00

15.01 Hospital-Based Health Clinic - RHC

II

PLAZA PRIMARY CARE WEST 268657 16020 02/01/2011 N O N 15.01

15.02 Hospital-Based Health Clinic - RHC

III

SOUTHEAST PEDIATRICS 268674 16020 07/16/2012 N O N 15.02

16.00 Hospital-Based Health Clinic - FQHC 16.00

17.00 Hospital-Based (CMHC) I 17.00

18.00 Renal Dialysis 18.00

19.00 Other 19.00

From:

1.00

To:

2.00

20.00 Cost Reporting Period (mm/dd/yyyy) 01/01/2015 12/31/2015 20.00

21.00 Type of Control (see instructions) 2 21.00

Inpatient PPS Information

22.00 Does this facility qualify and is it currently receiving payments for disproportionate

share hospital adjustment, in accordance with 42 CFR §412.106? In column 1, enter "Y"

for yes or "N" for no. Is this facility subject to 42 CFR Section §412.06(c)(2)(Pickle

amendment hospital?) In column 2, enter "Y" for yes or "N" for no.

Y N 22.00

22.01 Did this hospital receive interim uncompensated care payments for this cost reporting

period? Enter in column 1, "Y" for yes or "N" for no for the portion of the cost

reporting period occurring prior to October 1. Enter in column 2, "Y" for yes or "N"

for no for the portion of the cost reporting period occurring on or after October 1.

(see instructions)

Y Y 22.01

22.02 Is this a newly merged hospital that requires final uncompensated care payments to be

determined at cost report settlement? (see instructions) Enter in column 1, "Y" for yes

or "N" for no, for the portion of the cost reporting period prior to October 1. Enter

in column 2, "Y" for yes or "N" for no, for the portion of the cost reporting period on

or after October 1.

N N 22.02

22.03 Did this hospital receive a geographic reclassification from urban to rural as a result

of the OMB standards for delineating statistical areas adopted by CMS in FY2015? Enter

in column 1, "Y" for yes or "N" for no for the portion of the cost reporting period

prior to October 1. Enter in column 2, "Y" for yes or "N" for no for the portion of the

cost reporting period occurring on or after October 1. (see instructions) Does this

hospital contain at least 100 but not more than 499 beds (as counted in accordance with

42 CFR 412.105)? Enter in column 3, "Y" for yes or “N” for no.

N N 22.03

23.00 Which method is used to determine Medicaid days on lines 24 and/or 25 below? In column

1, enter 1 if date of admission, 2 if census days, or 3 if date of discharge. Is the

method of identifying the days in this cost reporting period different from the method

used in the prior cost reporting period? In column 2, enter "Y" for yes or "N" for no.

3 N 23.00

In-State

Medicaid

paid days

1.00

In-State

Medicaid

eligible

unpaid

days

2.00

Out-of

State

Medicaid

paid days

3.00

Out-of

State

Medicaid

eligible

unpaid

4.00

Medicaid

HMO days

5.00

Other

Medicaid

days

6.00

24.00 If this provider is an IPPS hospital, enter the

in-state Medicaid paid days in column 1, in-state

Medicaid eligible unpaid days in column 2,

out-of-state Medicaid paid days in column 3,

out-of-state Medicaid eligible unpaid days in column

4, Medicaid HMO paid and eligible but unpaid days in

column 5, and other Medicaid days in column 6.

4,585 832 638 0 68 120 24.00


MCRIF32 - 8.8.159.0 2 | Page


Date/Time Prepared:

Worksheet S-2

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


In-State

Medicaid

paid days

1.00

In-State

Medicaid

eligible

unpaid

days

2.00

Out-of

State

Medicaid

paid days

3.00

Out-of

State

Medicaid

eligible

unpaid

4.00

Medicaid

HMO days

5.00

Other

Medicaid

days

6.00

25.00 If this provider is an IRF, enter the in-state

Medicaid paid days in column 1, the in-state

Medicaid eligible unpaid days in column 2,

out-of-state Medicaid days in column 3, out-of-state

Medicaid eligible unpaid days in column 4, Medicaid

HMO paid and eligible but unpaid days in column 5.

153 88 0 0 0 25.00

Urban/Rural S

1.00

Date of Geogr

2.00

26.00 Enter your standard geographic classification (not wage) status at the beginning of the

cost reporting period. Enter "1" for urban or "2" for rural.

1 26.00

27.00 Enter your standard geographic classification (not wage) status at the end of the cost

reporting period. Enter in column 1, "1" for urban or "2" for rural. If applicable,

enter the effective date of the geographic reclassification in column 2.

1 27.00

35.00 If this is a sole community hospital (SCH), enter the number of periods SCH status in

effect in the cost reporting period.

0 35.00

Beginning:

1.00

Ending:

2.00

36.00 Enter applicable beginning and ending dates of SCH status. Subscript line 36 for number

of periods in excess of one and enter subsequent dates.

36.00

37.00 If this is a Medicare dependent hospital (MDH), enter the number of periods MDH status

is in effect in the cost reporting period.

0 37.00

38.00 If line 37 is 1, enter the beginning and ending dates of MDH status. If line 37 is

greater than 1, subscript this line for the number of periods in excess of one and

enter subsequent dates.

38.00

Y/N

1.00

Y/N

2.00

39.00 Does this facility qualify for the inpatient hospital payment adjustment for low volume

hospitals in accordance with 42 CFR §412.101(b)(2)(ii)? Enter in column 1 “Y” for yes

or “N” for no. Does the facility meet the mileage requirements in accordance with 42

CFR 412.101(b)(2)(ii)? Enter in column 2 "Y" for yes or "N" for no. (see instructions)

N N 39.00

40.00 Is this hospital subject to the HAC program reduction adjustment? Enter "Y" for yes or

"N" for no in column 1, for discharges prior to October 1. Enter "Y" for yes or "N" for

no in column 2, for discharges on or after October 1. (see instructions)

Y Y 40.00

V

1.00

XVIII

2.00

XIX

3.00

Prospective Payment System (PPS)-Capital

45.00 Does this facility qualify and receive Capital payment for disproportionate share in accordance

with 42 CFR Section §412.320? (see instructions)

N Y N 45.00

46.00 Is this facility eligible for additional payment exception for extraordinary circumstances

pursuant to 42 CFR §412.348(f)? If yes, complete Wkst. L, Pt. III and Wkst. L-1, Pt. I through

Pt. III.

N N N 46.00

47.00 Is this a new hospital under 42 CFR §412.300 PPS capital? Enter "Y for yes or "N" for no. N N N 47.00

48.00 Is the facility electing full federal capital payment? Enter "Y" for yes or "N" for no. N N N 48.00

Teaching Hospitals

56.00 Is this a hospital involved in training residents in approved GME programs? Enter "Y" for yes

or "N" for no.

N 56.00

57.00 If line 56 is yes, is this the first cost reporting period during which residents in approved

GME programs trained at this facility? Enter "Y" for yes or "N" for no in column 1. If column 1

is "Y" did residents start training in the first month of this cost reporting period? Enter "Y"

for yes or "N" for no in column 2. If column 2 is "Y", complete Worksheet E-4. If column 2 is

"N", complete Wkst. D, Parts III & IV and D-2, Pt. II, if applicable.

N 57.00

58.00 If line 56 is yes, did this facility elect cost reimbursement for physicians' services as

defined in CMS Pub. 15-1, chapter 21, §2148? If yes, complete Wkst. D-5.

N 58.00

59.00 Are costs claimed on line 100 of Worksheet A? If yes, complete Wkst. D-2, Pt. I. N 59.00

60.00 Are you claiming nursing school and/or allied health costs for a program that meets the

provider-operated criteria under §413.85? Enter "Y" for yes or "N" for no. (see instructions)

Y 60.00

Y/N

1.00

IME

2.00

Direct GME

3.00

IME

4.00

Direct GME

5.00

61.00 Did your hospital receive FTE slots under ACA

section 5503? Enter "Y" for yes or "N" for no in

column 1. (see instructions)

N 0.00 0.00 61.00

61.01 Enter the average number of unweighted primary care

FTEs from the hospital's 3 most recent cost reports

ending and submitted before March 23, 2010. (see

instructions)

0.00 0.00 61.01

61.02 Enter the current year total unweighted primary care

FTE count (excluding OB/GYN, general surgery FTEs,

and primary care FTEs added under section 5503 of

ACA). (see instructions)

0.00 0.00 61.02


MCRIF32 - 8.8.159.0 3 | Page


Date/Time Prepared:

Worksheet S-2

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Y/N

1.00

IME

2.00

Direct GME

3.00

IME

4.00

Direct GME

5.00

61.03 Enter the base line FTE count for primary care

and/or general surgery residents, which is used for

determining compliance with the 75% test. (see

instructions)

0.00 0.00 61.03

61.04 Enter the number of unweighted primary care/or

surgery allopathic and/or osteopathic FTEs in the

current cost reporting period.(see instructions).

0.00 0.00 61.04

61.05 Enter the difference between the baseline primary

and/or general surgery FTEs and the current year's

primary care and/or general surgery FTE counts (line

61.04 minus line 61.03). (see instructions)

0.00 0.00 61.05

61.06 Enter the amount of ACA §5503 award that is being

used for cap relief and/or FTEs that are nonprimary

care or general surgery. (see instructions)

0.00 0.00 61.06

Program Name

1.00

Program Code

2.00

Unweighted

IME FTE Count

3.00

Unweighted

Direct GME

FTE Count

4.00

61.10 Of the FTEs in line 61.05, specify each new program

specialty, if any, and the number of FTE residents

for each new program. (see instructions) Enter in

column 1, the program name, enter in column 2, the

program code, enter in column 3, the IME FTE

unweighted count and enter in column 4, direct GME

FTE unweighted count.

0.00 0.00 61.10

61.20 Of the FTEs in line 61.05, specify each expanded

program specialty, if any, and the number of FTE

residents for each expanded program. (see

instructions) Enter in column 1, the program name,

enter in column 2, the program code, enter in column

3, the IME FTE unweighted count and enter in column

4, direct GME FTE unweighted count.

0.00 0.00 61.20

1.00

ACA Provisions Affecting the Health Resources and Services Administration (HRSA)

62.00 Enter the number of FTE residents that your hospital trained in this cost reporting period for which

your hospital received HRSA PCRE funding (see instructions)

0.00 62.00

62.01 Enter the number of FTE residents that rotated from a Teaching Health Center (THC) into your hospital

during in this cost reporting period of HRSA THC program. (see instructions)

0.00 62.01

Teaching Hospitals that Claim Residents in Nonprovider Settings

63.00 Has your facility trained residents in nonprovider settings during this cost reporting period? Enter

"Y" for yes or "N" for no in column 1. If yes, complete lines 64-67. (see instructions)

N 63.00

Unweighted

FTEs

Nonprovider

Site

1.00

Unweighted

FTEs in

Hospital

2.00

Ratio (col.

1/ (col. 1 +

col. 2))

3.00

Section 5504 of the ACA Base Year FTE Residents in Nonprovider Settings--This base year is your cost reporting

period that begins on or after July 1, 2009 and before June 30, 2010.

64.00 Enter in column 1, if line 63 is yes, or your facility trained residents

in the base year period, the number of unweighted non-primary care

resident FTEs attributable to rotations occurring in all nonprovider

settings. Enter in column 2 the number of unweighted non-primary care

resident FTEs that trained in your hospital. Enter in column 3 the ratio

of (column 1 divided by (column 1 + column 2)). (see instructions)

0.00 0.00 0.000000 64.00

1.00

Program Name Program Code

2.00

Unweighted

FTEs

Nonprovider

Site

3.00

Unweighted

FTEs in

Hospital

4.00

Ratio (col.

3/ (col. 3 +

col. 4))

5.00


MCRIF32 - 8.8.159.0 4 | Page


Date/Time Prepared:

Worksheet S-2

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


1.00


2.00

Unweighted

FTEs

Nonprovider

Site

3.00

Unweighted

FTEs in

Hospital

4.00

Ratio (col.

3/ (col. 3 +

col. 4))

5.00

65.00 Enter in column 1, if line 63

is yes, or your facility

trained residents in the base

year period, the program name

associated with primary care

FTEs for each primary care

program in which you trained

residents. Enter in column 2,

the program code, enter in

column 3, the number of

unweighted primary care FTE

residents attributable to

rotations occurring in all

non-provider settings. Enter in


unweighted primary care

resident FTEs that trained in

your hospital. Enter in column

5, the ratio of (column 3

divided by (column 3 + column

4)). (see instructions)

65.000.0000000.000.00

Unweighted

FTEs

Nonprovider

Site

1.00

Unweighted

FTEs in

Hospital

2.00

Ratio (col.

1/ (col. 1 +

col. 2))

3.00

Section 5504 of the ACA Current Year FTE Residents in Nonprovider Settings--Effective for cost reporting periods

beginning on or after July 1, 2010

66.00 Enter in column 1 the number of unweighted non-primary care resident

FTEs attributable to rotations occurring in all nonprovider settings.

Enter in column 2 the number of unweighted non-primary care resident

FTEs that trained in your hospital. Enter in column 3 the ratio of

(column 1 divided by (column 1 + column 2)). (see instructions)

0.00 0.00 0.000000 66.00

1.00


2.00

Unweighted

FTEs

Nonprovider

Site

3.00

Unweighted

FTEs in

Hospital

4.00

Ratio (col.

3/ (col. 3 +

col. 4))

5.00

67.00 Enter in column 1, the program

name associated with each of

your primary care programs in

which you trained residents.

Enter in column 2, the program

code. Enter in column 3, the

number of unweighted primary

care FTE residents attributable

to rotations occurring in all

non-provider settings. Enter in


unweighted primary care

resident FTEs that trained in

your hospital. Enter in column

5, the ratio of (column 3

divided by (column 3 + column

4)). (see instructions)

67.000.0000000.000.00

1.00 2.00 3.00

Inpatient Psychiatric Facility PPS

70.00 Is this facility an Inpatient Psychiatric Facility (IPF), or does it contain an IPF subprovider?

Enter "Y" for yes or "N" for no.

Y 70.00

71.00 If line 70 yes: Column 1: Did the facility have an approved GME teaching program in the most

recent cost report filed on or before November 15, 2004? Enter "Y" for yes or "N" for no. (see

42 CFR 412.424(d)(1)(iii)(c)) Column 2: Did this facility train residents in a new teaching

program in accordance with 42 CFR 412.424 (d)(1)(iii)(D)? Enter "Y" for yes or "N" for no.

Column 3: If column 2 is Y, indicate which program year began during this cost reporting period.

(see instructions)

N 0 71.00

Inpatient Rehabilitation Facility PPS

75.00 Is this facility an Inpatient Rehabilitation Facility (IRF), or does it contain an IRF

subprovider? Enter "Y" for yes and "N" for no.

Y 75.00


MCRIF32 - 8.8.159.0 5 | Page


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Part I

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Period:

To

From 01/01/2015

12/31/2015


1.00 2.00 3.00

76.00 If line 75 yes: Column 1: Did the facility have an approved GME teaching program in the most

recent cost reporting period ending on or before November 15, 2004? Enter "Y" for yes or "N" for

no. Column 2: Did this facility train residents in a new teaching program in accordance with 42

CFR 412.424 (d)(1)(iii)(D)? Enter "Y" for yes or "N" for no. Column 3: If column 2 is Y,

indicate which program year began during this cost reporting period. (see instructions)

N 0 76.00

1.00

Long Term Care Hospital PPS

80.00 Is this a long term care hospital (LTCH)? Enter "Y" for yes and "N" for no. N 80.00

81.00 Is this a LTCH co-located within another hospital for part or all of the cost reporting period? Enter

"Y" for yes and "N" for no.

N 81.00

TEFRA Providers

85.00 Is this a new hospital under 42 CFR Section §413.40(f)(1)(i) TEFRA? Enter "Y" for yes or "N" for no. N 85.00

86.00 Did this facility establish a new Other subprovider (excluded unit) under 42 CFR Section

§413.40(f)(1)(ii)? Enter "Y" for yes and "N" for no.

86.00

87.00 Is this hospital a "subclause (II)" LTCH classified under section 1886(d)(1)(B)(iv)(II)? Enter "Y"

for yes or "N" for no.

N 87.00

V

1.00

XIX

2.00

Title V and XIX Services

90.00 Does this facility have title V and/or XIX inpatient hospital services? Enter "Y" for

yes or "N" for no in the applicable column.

N Y 90.00

91.00 Is this hospital reimbursed for title V and/or XIX through the cost report either in

full or in part? Enter "Y" for yes or "N" for no in the applicable column.

N Y 91.00

92.00 Are title XIX NF patients occupying title XVIII SNF beds (dual certification)? (see

instructions) Enter "Y" for yes or "N" for no in the applicable column.

N 92.00

93.00 Does this facility operate an ICF/IID facility for purposes of title V and XIX? Enter

"Y" for yes or "N" for no in the applicable column.

N N 93.00

94.00 Does title V or XIX reduce capital cost? Enter "Y" for yes, and "N" for no in the

applicable column.

N N 94.00

95.00 If line 94 is "Y", enter the reduction percentage in the applicable column. 0.00 0.00 95.00

96.00 Does title V or XIX reduce operating cost? Enter "Y" for yes or "N" for no in the

applicable column.

N N 96.00

97.00 If line 96 is "Y", enter the reduction percentage in the applicable column. 0.00 0.00 97.00

Rural Providers

105.00 Does this hospital qualify as a critical access hospital (CAH)? N 105.00

106.00 If this facility qualifies as a CAH, has it elected the all-inclusive method of payment

for outpatient services? (see instructions)

106.00

107.00 If this facility qualifies as a CAH, is it eligible for cost reimbursement for I&R

training programs? Enter "Y" for yes or "N" for no in column 1. (see instructions) If

yes, the GME elimination is not made on Wkst. B, Pt. I, col. 25 and the program is cost

reimbursed. If yes complete Wkst. D-2, Pt. II.

107.00

108.00 Is this a rural hospital qualifying for an exception to the CRNA fee schedule? See 42

CFR Section §412.113(c). Enter "Y" for yes or "N" for no.

N 108.00

Physical

1.00

Occupational

2.00

Speech

3.00

Respiratory

4.00

109.00 If this hospital qualifies as a CAH or a cost provider, are

therapy services provided by outside supplier? Enter "Y"

for yes or "N" for no for each therapy.

N N N N 109.00

1.00

110.00 Did this hospital participate in the Rural Community Hospital Demonstration project (410A Demo)for

the current cost reporting period? Enter "Y" for yes or "N" for no.

N 110.00

1.00 2.00 3.00

Miscellaneous Cost Reporting Information

115.00 Is this an all-inclusive rate provider? Enter "Y" for yes or "N" for no in column 1. If column 1

is yes, enter the method used (A, B, or E only) in column 2. If column 2 is "E", enter in column

3 either "93" percent for short term hospital or "98" percent for long term care (includes

psychiatric, rehabilitation and long term hospitals providers) based on the definition in CMS

Pub.15-1, chapter 22, §2208.1.

N 0 115.00

116.00 Is this facility classified as a referral center? Enter "Y" for yes or "N" for no. Y 116.00

117.00 Is this facility legally-required to carry malpractice insurance? Enter "Y" for yes or "N" for

no.

Y 117.00

118.00 Is the malpractice insurance a claims-made or occurrence policy? Enter 1 if the policy is

claim-made. Enter 2 if the policy is occurrence.

1 118.00


MCRIF32 - 8.8.159.0 6 | Page


Date/Time Prepared:

Worksheet S-2

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Premiums

1.00

Losses

2.00

Insurance

3.00

118.01 List amounts of malpractice premiums and paid losses: 3,141,112 114,325 0118.01

1.00 2.00

118.02 Are malpractice premiums and paid losses reported in a cost center other than the

Administrative and General? If yes, submit supporting schedule listing cost centers

and amounts contained therein.

Y 118.02

119.00 DO NOT USE THIS LINE 119.00

120.00 Is this a SCH or EACH that qualifies for the Outpatient Hold Harmless provision in ACA

§3121 and applicable amendments? (see instructions) Enter in column 1, "Y" for yes or

"N" for no. Is this a rural hospital with < 100 beds that qualifies for the Outpatient

Hold Harmless provision in ACA §3121 and applicable amendments? (see instructions)

Enter in column 2, "Y" for yes or "N" for no.

N N 120.00

121.00 Did this facility incur and report costs for high cost implantable devices charged to

patients? Enter "Y" for yes or "N" for no.

Y 121.00

Transplant Center Information

125.00 Does this facility operate a transplant center? Enter "Y" for yes and "N" for no. If

yes, enter certification date(s) (mm/dd/yyyy) below.

N 125.00

126.00 If this is a Medicare certified kidney transplant center, enter the certification date

in column 1 and termination date, if applicable, in column 2.

126.00

127.00 If this is a Medicare certified heart transplant center, enter the certification date


127.00

128.00 If this is a Medicare certified liver transplant center, enter the certification date


128.00

129.00 If this is a Medicare certified lung transplant center, enter the certification date in

column 1 and termination date, if applicable, in column 2.

129.00

130.00 If this is a Medicare certified pancreas transplant center, enter the certification

date in column 1 and termination date, if applicable, in column 2.

130.00

131.00 If this is a Medicare certified intestinal transplant center, enter the certification

date in column 1 and termination date, if applicable, in column 2.

131.00

132.00 If this is a Medicare certified islet transplant center, enter the certification date


132.00

133.00 If this is a Medicare certified other transplant center, enter the certification date


133.00

134.00 If this is an organ procurement organization (OPO), enter the OPO number in column 1

and termination date, if applicable, in column 2.

134.00

All Providers

140.00 Are there any related organization or home office costs as defined in CMS Pub. 15-1,

chapter 10? Enter "Y" for yes or "N" for no in column 1. If yes, and home office costs

are claimed, enter in column 2 the home office chain number. (see instructions)

Y HB0719 140.00

1.00 2.00 3.00

If this facility is part of a chain organization, enter on lines 141 through 143 the name and address of the home

office and enter the home office contractor name and contractor number.

141.00 Name: SOUTHEAST HOSPITAL Contractor's Name:WPS Contractor's Number:05301 141.00

142.00 Street:1701 LACEY STREET PO Box: 142.00

143.00 City: CAPE GIRARDEAU State: MO Zip Code: 63701 143.00

1.00

144.00 Are provider based physicians' costs included in Worksheet A? Y 144.00

1.00 2.00

145.00 If costs for renal services are claimed on Wkst. A, line 74, are the costs for

inpatient services only? Enter "Y" for yes or "N" for no in column 1. If column 1 is

no, does the dialysis facility include Medicare utilization for this cost reporting

period? Enter "Y" for yes or "N" for no in column 2.

N 145.00

146.00 Has the cost allocation methodology changed from the previously filed cost report?

Enter "Y" for yes or "N" for no in column 1. (See CMS Pub. 15-2, chapter 40, §4020) If

yes, enter the approval date (mm/dd/yyyy) in column 2.

N 146.00

1.00

147.00 Was there a change in the statistical basis? Enter "Y" for yes or "N" for no. N 147.00

148.00 Was there a change in the order of allocation? Enter "Y" for yes or "N" for no. N 148.00

149.00 Was there a change to the simplified cost finding method? Enter "Y" for yes or "N" for no. N 149.00


MCRIF32 - 8.8.159.0 7 | Page


Date/Time Prepared:

Worksheet S-2

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Part A

1.00

Part B

2.00

Title V

3.00

Title XIX

4.00

Does this facility contain a provider that qualifies for an exemption from the application of the lower of costs

or charges? Enter "Y" for yes or "N" for no for each component for Part A and Part B. (See 42 CFR §413.13)

155.00 Hospital N N N N 155.00

156.00 Subprovider - IPF N N N N 156.00

157.00 Subprovider - IRF N N N N 157.00

158.00 SUBPROVIDER 158.00

159.00 SNF N N N N 159.00

160.00 HOME HEALTH AGENCY N N N N 160.00

161.00 CMHC N N N 161.00

1.00

Multicampus

165.00 Is this hospital part of a Multicampus hospital that has one or more campuses in different CBSAs?

Enter "Y" for yes or "N" for no.

N 165.00

Name

0

County

1.00

State

2.00

Zip Code

3.00

CBSA

4.00

FTE/Campus

5.00

166.00 If line 165 is yes, for each

campus enter the name in column

0, county in column 1, state in

column 2, zip code in column 3,

CBSA in column 4, FTE/Campus in

column 5 (see instructions)

0.00166.00

1.00

Health Information Technology (HIT) incentive in the American Recovery and Reinvestment Act

167.00 Is this provider a meaningful user under §1886(n)? Enter "Y" for yes or "N" for no. Y 167.00

168.00 If this provider is a CAH (line 105 is "Y") and is a meaningful user (line 167 is "Y"), enter the

reasonable cost incurred for the HIT assets (see instructions)

0168.00

168.01 If this provider is a CAH and is not a meaningful user, does this provider qualify for a hardship

exception under §413.70(a)(6)(ii)? Enter "Y" for yes or "N" for no. (see instructions)

168.01

169.00 If this provider is a meaningful user (line 167 is "Y") and is not a CAH (line 105 is "N"), enter the

transition factor. (see instructions)

0.50169.00

Beginning

1.00

Ending

2.00

170.00 Enter in columns 1 and 2 the EHR beginning date and ending date for the reporting

period respectively (mm/dd/yyyy)

07/01/2015 09/30/2015 170.00

1.00

171.00 If line 167 is "Y", does this provider have any days for individuals enrolled in section 1876

Medicare cost plans reported on Wkst. S-3, Pt. I, line 2, col. 6? Enter "Y" for yes and "N" for no.

(see instructions)

N 171.00


MCRIF32 - 8.8.159.0 8 | Page


Date/Time Prepared:

Worksheet S-2

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110HOSPITAL AND HOSPITAL HEALTH CARE REIMBURSEMENT QUESTIONNAIRE

Y/N Date

1.00 2.00

General Instruction: Enter Y for all YES responses. Enter N for all NO responses. Enter all dates in the

mm/dd/yyyy format.

COMPLETED BY ALL HOSPITALS

Provider Organization and Operation

1.00 Has the provider changed ownership immediately prior to the beginning of the cost

reporting period? If yes, enter the date of the change in column 2. (see instructions)

N 1.00

Y/N Date V/I

1.00 2.00 3.00

2.00 Has the provider terminated participation in the Medicare Program? If

yes, enter in column 2 the date of termination and in column 3, "V" for

voluntary or "I" for involuntary.

N 2.00

3.00 Is the provider involved in business transactions, including management

contracts, with individuals or entities (e.g., chain home offices, drug

or medical supply companies) that are related to the provider or its

officers, medical staff, management personnel, or members of the board

of directors through ownership, control, or family and other similar

relationships? (see instructions)

N 3.00

Y/N Type Date

1.00 2.00 3.00

Financial Data and Reports

4.00 Column 1: Were the financial statements prepared by a Certified Public

Accountant? Column 2: If yes, enter "A" for Audited, "C" for Compiled,

or "R" for Reviewed. Submit complete copy or enter date available in

column 3. (see instructions) If no, see instructions.

Y A 4.00

5.00 Are the cost report total expenses and total revenues different from

those on the filed financial statements? If yes, submit reconciliation.

Y 5.00

Y/N Legal Oper.

1.00 2.00

Approved Educational Activities

6.00 Column 1: Are costs claimed for nursing school? Column 2: If yes, is the provider is

the legal operator of the program?

Y Y 6.00

7.00 Are costs claimed for Allied Health Programs? If "Y" see instructions. Y 7.00

8.00 Were nursing school and/or allied health programs approved and/or renewed during the

cost reporting period? If yes, see instructions.

N 8.00

9.00 Are costs claimed for Interns and Residents in an approved graduate medical education

program in the current cost report? If yes, see instructions.

N 9.00

10.00 Was an approved Intern and Resident GME program initiated or renewed in the current

cost reporting period? If yes, see instructions.

N 10.00

11.00 Are GME cost directly assigned to cost centers other than I & R in an Approved

Teaching Program on Worksheet A? If yes, see instructions.

N 11.00

Y/N

1.00

Bad Debts

12.00 Is the provider seeking reimbursement for bad debts? If yes, see instructions. Y 12.00

13.00 If line 12 is yes, did the provider's bad debt collection policy change during this cost reporting

period? If yes, submit copy.

N 13.00

14.00 If line 12 is yes, were patient deductibles and/or co-payments waived? If yes, see instructions. N 14.00

Bed Complement

15.00 Did total beds available change from the prior cost reporting period? If yes, see instructions. N 15.00

Part A Part B

Description Y/N Date Y/N

0 1.00 2.00 3.00

PS&R Data

16.00 Was the cost report prepared using the PS&R

Report only? If either column 1 or 3 is yes,

enter the paid-through date of the PS&R

Report used in columns 2 and 4 .(see

instructions)

Y 04/12/2016 Y 16.00


Report for totals and the provider's records

for allocation? If either column 1 or 3 is

yes, enter the paid-through date in columns

2 and 4. (see instructions)

N N 17.00

18.00 If line 16 or 17 is yes, were adjustments

made to PS&R Report data for additional

claims that have been billed but are not

included on the PS&R Report used to file

this cost report? If yes, see instructions.

N N 18.00


made to PS&R Report data for corrections of

other PS&R Report information? If yes, see

instructions.

N N 19.00


made to PS&R Report data for Other? Describe

the other adjustments:

N N 20.00


MCRIF32 - 8.8.159.0 9 | Page


Date/Time Prepared:

Worksheet S-2

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Part A Part B

Description Y/N Date Y/N

0 1.00 2.00 3.00

21.00 Was the cost report prepared only using the

provider's records? If yes, see

instructions.

N N 21.00

1.00

COMPLETED BY COST REIMBURSED AND TEFRA HOSPITALS ONLY (EXCEPT CHILDRENS HOSPITALS)

Capital Related Cost

22.00 Have assets been relifed for Medicare purposes? If yes, see instructions 22.00

23.00 Have changes occurred in the Medicare depreciation expense due to appraisals made during the cost

reporting period? If yes, see instructions.

23.00

24.00 Were new leases and/or amendments to existing leases entered into during this cost reporting period?

If yes, see instructions

24.00

25.00 Have there been new capitalized leases entered into during the cost reporting period? If yes, see

instructions.

25.00

26.00 Were assets subject to Sec.2314 of DEFRA acquired during the cost reporting period? If yes, see

instructions.

26.00

27.00 Has the provider's capitalization policy changed during the cost reporting period? If yes, submit

copy.

27.00

Interest Expense

28.00 Were new loans, mortgage agreements or letters of credit entered into during the cost reporting

period? If yes, see instructions.

28.00

29.00 Did the provider have a funded depreciation account and/or bond funds (Debt Service Reserve Fund)

treated as a funded depreciation account? If yes, see instructions

29.00

30.00 Has existing debt been replaced prior to its scheduled maturity with new debt? If yes, see

instructions.

30.00

31.00 Has debt been recalled before scheduled maturity without issuance of new debt? If yes, see

instructions.

31.00

Purchased Services

32.00 Have changes or new agreements occurred in patient care services furnished through contractual

arrangements with suppliers of services? If yes, see instructions.

32.00

33.00 If line 32 is yes, were the requirements of Sec. 2135.2 applied pertaining to competitive bidding? If

no, see instructions.

33.00

Provider-Based Physicians

34.00 Are services furnished at the provider facility under an arrangement with provider-based physicians?

If yes, see instructions.

34.00

35.00 If line 34 is yes, were there new agreements or amended existing agreements with the provider-based

physicians during the cost reporting period? If yes, see instructions.

35.00

Y/N Date

1.00 2.00

Home Office Costs

36.00 Were home office costs claimed on the cost report? Y 36.00

37.00 If line 36 is yes, has a home office cost statement been prepared by the home office?

If yes, see instructions.

Y 37.00

38.00 If line 36 is yes , was the fiscal year end of the home office different from that of

the provider? If yes, enter in column 2 the fiscal year end of the home office.

N 38.00

39.00 If line 36 is yes, did the provider render services to other chain components? If yes,

see instructions.

Y 39.00

40.00 If line 36 is yes, did the provider render services to the home office? If yes, see

instructions.

N 40.00

1.00 2.00

Cost Report Preparer Contact Information

41.00 Enter the first name, last name and the title/position

held by the cost report preparer in columns 1, 2, and 3,

respectively.

41.00BKD LLP

42.00 Enter the employer/company name of the cost report

preparer.

42.00BKD, LLP

43.00 Enter the telephone number and email address of the cost

report preparer in columns 1 and 2, respectively.

43.00417.865.8701 [email protected]


MCRIF32 - 8.8.159.0 10 | Page


Date/Time Prepared:

Worksheet S-2

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Part B

Date

4.00

PS&R Data


Report only? If either column 1 or 3 is yes,

enter the paid-through date of the PS&R

Report used in columns 2 and 4 .(see

instructions)

04/12/2016 16.00


Report for totals and the provider's records

for allocation? If either column 1 or 3 is

yes, enter the paid-through date in columns

2 and 4. (see instructions)

17.00


made to PS&R Report data for additional

claims that have been billed but are not

included on the PS&R Report used to file

this cost report? If yes, see instructions.

18.00


made to PS&R Report data for corrections of

other PS&R Report information? If yes, see

instructions.

19.00


made to PS&R Report data for Other? Describe

the other adjustments:

20.00

21.00 Was the cost report prepared only using the

provider's records? If yes, see

instructions.

21.00

3.00

Cost Report Preparer Contact Information

41.00 Enter the first name, last name and the title/position

held by the cost report preparer in columns 1, 2, and 3,

respectively.

41.00COST REPORTS

42.00 Enter the employer/company name of the cost report

preparer.

42.00

43.00 Enter the telephone number and email address of the cost

report preparer in columns 1 and 2, respectively.

43.00


MCRIF32 - 8.8.159.0 11 | Page


Date/Time Prepared:

Worksheet S-3

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX STATISTICAL DATA

I/P Days /

O/P Visits /

Trips

Component Worksheet A

Line Number

No. of Beds Bed Days

Available

CAH Hours Title V

1.00 2.00 3.00 4.00 5.00

1.00 Hospital Adults & Peds. (columns 5, 6, 7 and

8 exclude Swing Bed, Observation Bed and

Hospice days)(see instructions for col. 2

for the portion of LDP room available beds)

30.00 170 62,050 0.00 0 1.00

2.00 HMO and other (see instructions) 2.00

3.00 HMO IPF Subprovider 3.00

4.00 HMO IRF Subprovider 4.00

5.00 Hospital Adults & Peds. Swing Bed SNF 0 5.00

6.00 Hospital Adults & Peds. Swing Bed NF 0 6.00

7.00 Total Adults and Peds. (exclude observation

beds) (see instructions)

170 62,050 0.00 0 7.00

8.00 INTENSIVE CARE UNIT 8.00

9.00 CORONARY CARE UNIT 9.00

10.00 BURN INTENSIVE CARE UNIT 10.00

10.01 ADULT SPECIAL CARE 33.01 14 5,110 0.00 0 10.01

11.00 SURGICAL INTENSIVE CARE UNIT 11.00

11.01 CARDIOTHORACIC ICU 34.01 12 4,380 0.00 0 11.01

12.00 NEONATOLOGY 12.00

13.00 NURSERY 43.00 0 13.00

14.00 Total (see instructions) 196 71,540 0.00 0 14.00

15.00 CAH visits 0 15.00

16.00 SUBPROVIDER - IPF 40.00 13 4,745 0 16.00

17.00 SUBPROVIDER - IRF 41.00 13 4,745 0 17.00


19.00 SKILLED NURSING FACILITY 19.00

20.00 NURSING FACILITY 20.00

21.00 OTHER LONG TERM CARE 21.00

22.00 HOME HEALTH AGENCY 101.00 0 22.00

23.00 AMBULATORY SURGICAL CENTER (D.P.) 23.00

24.00 HOSPICE 116.00 0 0 24.00

24.10 HOSPICE (non-distinct part) 30.00 24.10

25.00 CMHC - CMHC 25.00

26.00 RURAL HEALTH CLINIC 88.00 0 26.00

26.01 RURAL HEALTH CLINIC II 88.01 0 26.01

26.02 RURAL HEALTH CLINIC III 88.02 0 26.02

26.25 FEDERALLY QUALIFIED HEALTH CENTER 26.25

27.00 Total (sum of lines 14-26) 222 27.00

28.00 Observation Bed Days 0 28.00

29.00 Ambulance Trips 29.00

30.00 Employee discount days (see instruction) 30.00

31.00 Employee discount days - IRF 31.00

32.00 Labor & delivery days (see instructions) 0 0 32.00

32.01 Total ancillary labor & delivery room

outpatient days (see instructions)

32.01

33.00 LTCH non-covered days 33.00


MCRIF32 - 8.8.159.0 12 | Page


Date/Time Prepared:

Worksheet S-3

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


I/P Days / O/P Visits / Trips Full Time Equivalents

Component Title XVIII Title XIX Total All

Patients

Total Interns

& Residents

Employees On

Payroll

6.00 7.00 8.00 9.00 10.00





16,163 2,898 27,883 1.00

2.00 HMO and other (see instructions) 2,512 1,538 2.00

3.00 HMO IPF Subprovider 35 371 3.00

4.00 HMO IRF Subprovider 117 88 4.00

5.00 Hospital Adults & Peds. Swing Bed SNF 0 0 0 5.00

6.00 Hospital Adults & Peds. Swing Bed NF 0 0 6.00



16,163 2,898 27,883 7.00




10.01 ADULT SPECIAL CARE 1,492 352 2,666 10.01


11.01 CARDIOTHORACIC ICU 1,135 136 2,024 11.01


13.00 NURSERY 1,199 2,858 13.00

14.00 Total (see instructions) 18,790 4,585 35,431 0.00 1,698.34 14.00

15.00 CAH visits 0 0 0 15.00

16.00 SUBPROVIDER - IPF 936 785 2,928 0.00 19.24 16.00

17.00 SUBPROVIDER - IRF 1,615 153 2,348 0.00 16.16 17.00





22.00 HOME HEALTH AGENCY 5,982 354 6,816 0.00 15.07 22.00


24.00 HOSPICE 0 0 0 0.00 18.19 24.00

24.10 HOSPICE (non-distinct part) 0 0 0 24.10

25.00 CMHC - CMHC 25.00

26.00 RURAL HEALTH CLINIC 0 0 0 0.00 0.00 26.00

26.01 RURAL HEALTH CLINIC II 7,087 2,668 25,631 0.00 24.76 26.01

26.02 RURAL HEALTH CLINIC III 0 9,253 19,347 0.00 14.86 26.02


27.00 Total (sum of lines 14-26) 0.00 1,806.62 27.00

28.00 Observation Bed Days 864 4,522 28.00

29.00 Ambulance Trips 0 29.00

30.00 Employee discount days (see instruction) 577 30.00

31.00 Employee discount days - IRF 68 31.00

32.00 Labor & delivery days (see instructions) 0 120 414 32.00



0 32.01

33.00 LTCH non-covered days 0 33.00


MCRIF32 - 8.8.159.0 13 | Page


Date/Time Prepared:

Worksheet S-3

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Full Time

Equivalents

Discharges

Component Nonpaid

Workers

Title V Title XVIII Title XIX Total All

Patients

11.00 12.00 13.00 14.00 15.00





0 4,061 1,018 8,160 1.00

2.00 HMO and other (see instructions) 474 438 2.00

3.00 HMO IPF Subprovider 321 3.00

4.00 HMO IRF Subprovider 19 4.00

5.00 Hospital Adults & Peds. Swing Bed SNF 5.00

6.00 Hospital Adults & Peds. Swing Bed NF 6.00



7.00




10.01 ADULT SPECIAL CARE 10.01


11.01 CARDIOTHORACIC ICU 11.01


13.00 NURSERY 13.00

14.00 Total (see instructions) 0.00 0 4,061 1,018 8,160 14.00

15.00 CAH visits 15.00

16.00 SUBPROVIDER - IPF 0.00 0 184 216 800 16.00

17.00 SUBPROVIDER - IRF 0.00 0 125 12 185 17.00





22.00 HOME HEALTH AGENCY 0.00 22.00


24.00 HOSPICE 0.00 24.00

24.10 HOSPICE (non-distinct part) 24.10

25.00 CMHC - CMHC 25.00

26.00 RURAL HEALTH CLINIC 0.00 26.00

26.01 RURAL HEALTH CLINIC II 0.00 26.01

26.02 RURAL HEALTH CLINIC III 0.00 26.02


27.00 Total (sum of lines 14-26) 0.00 27.00

28.00 Observation Bed Days 28.00

29.00 Ambulance Trips 29.00

30.00 Employee discount days (see instruction) 30.00

31.00 Employee discount days - IRF 31.00

32.00 Labor & delivery days (see instructions) 32.00



32.01

33.00 LTCH non-covered days 33.00


MCRIF32 - 8.8.159.0 14 | Page


Date/Time Prepared:

Worksheet S-3

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110HOSPITAL WAGE INDEX INFORMATION

Worksheet A

Line Number

Amount

Reported

Reclassificat

ion of

Salaries

(from

Worksheet

A-6)

Adjusted

Salaries

(col.2 ± col.

3)

Paid Hours

Related to

Salaries in

col. 4

Average

Hourly Wage

(col. 4 ÷

col. 5)

1.00 2.00 3.00 4.00 5.00 6.00

PART II - WAGE DATA

SALARIES

1.00 Total salaries (see

instructions)

200.00 116,593,911 0 116,593,911 3,757,781.60 31.03 1.00

2.00 Non-physician anesthetist Part

A

0 0 0 0.00 0.00 2.00


B

0 0 0 0.00 0.00 3.00

4.00 Physician-Part A -

Administrative

174,839 0 174,839 708.53 246.76 4.00

4.01 Physicians - Part A - Teaching 0 0 0 0.00 0.00 4.01

5.00 Physician-Part B 16,827,095 0 16,827,095 119,126.58 141.25 5.00

6.00 Non-physician-Part B 1,296,081 0 1,296,081 65,597.16 19.76 6.00

7.00 Interns & residents (in an

approved program)

21.00 0 0 0 0.00 0.00 7.00

7.01 Contracted interns and

residents (in an approved

programs)

0 0 0 0.00 0.00 7.01

8.00 Home office personnel 11,212,028 0 11,212,028 449,098.50 24.97 8.00

9.00 SNF 44.00 0 0 0 0.00 0.00 9.00

10.00 Excluded area salaries (see

instructions)

32,547,837 49,736 32,597,573 746,261.99 43.68 10.00

OTHER WAGES & RELATED COSTS

11.00 Contract labor: Direct Patient

Care

0 0 0 0.00 0.00 11.00

12.00 Contract labor: Top level

management and other

management and administrative

services

0 0 0 0.00 0.00 12.00

13.00 Contract labor: Physician-Part

A - Administrative

0 0 0 0.00 0.00 13.00

14.00 Home office salaries &

wage-related costs

12,270,382 0 12,270,382 424,424.72 28.91 14.00

15.00 Home office: Physician Part A

- Administrative

0 0 0 0.00 0.00 15.00

16.00 Home office and Contract

Physicians Part A - Teaching

0 0 0 0.00 0.00 16.00

WAGE-RELATED COSTS

17.00 Wage-related costs (core) (see

instructions)

14,432,283 0 14,432,283 17.00

18.00 Wage-related costs (other)

(see instructions)

0 0 0 18.00

19.00 Excluded areas 5,058,827 0 5,058,827 19.00


A

0 0 0 20.00


B

0 0 0 21.00

22.00 Physician Part A -

Administrative

22,926 0 22,926 22.00

22.01 Physician Part A - Teaching 0 0 0 22.01

23.00 Physician Part B 1,815,225 0 1,815,225 23.00

24.00 Wage-related costs (RHC/FQHC) 302,270 0 302,270 24.00

25.00 Interns & residents (in an

approved program)

0 0 0 25.00

OVERHEAD COSTS - DIRECT SALARIES

26.00 Employee Benefits Department 4.00 415,208 0 415,208 15,424.60 26.92 26.00

27.00 Administrative & General 5.00 13,645,870 0 13,645,870 573,122.64 23.81 27.00

28.00 Administrative & General under

contract (see inst.)

0 0 0 0.00 0.00 28.00

29.00 Maintenance & Repairs 6.00 1,945,663 0 1,945,663 81,752.99 23.80 29.00

30.00 Operation of Plant 7.00 0 0 0 0.00 0.00 30.00

31.00 Laundry & Linen Service 8.00 0 0 0 0.00 0.00 31.00

32.00 Housekeeping 9.00 1,958,009 0 1,958,009 166,050.86 11.79 32.00

33.00 Housekeeping under contract

(see instructions)

0 0 0 0.00 0.00 33.00

34.00 Dietary 10.00 1,168,176 0 1,168,176 97,828.04 11.94 34.00

35.00 Dietary under contract (see

instructions)

0 0 0 0.00 0.00 35.00

36.00 Cafeteria 11.00 0 0 0 0.00 0.00 36.00

37.00 Maintenance of Personnel 12.00 0 0 0 0.00 0.00 37.00

38.00 Nursing Administration 13.00 2,706,479 -49,736 2,656,743 100,801.51 26.36 38.00


MCRIF32 - 8.8.159.0 15 | Page


Date/Time Prepared:

Worksheet S-3

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Worksheet A

Line Number

Amount

Reported

Reclassificat

ion of

Salaries

(from

Worksheet

A-6)

Adjusted

Salaries

(col.2 ± col.

3)

Paid Hours

Related to

Salaries in

col. 4

Average

Hourly Wage

(col. 4 ÷

col. 5)

1.00 2.00 3.00 4.00 5.00 6.00

39.00 Central Services and Supply 14.00 817,399 0 817,399 48,079.87 17.00 39.00

40.00 Pharmacy 15.00 0 0 0 0.00 0.00 40.00

41.00 Medical Records & Medical

Records Library

16.00 0 0 0 0.00 0.00 41.00

42.00 Social Service 17.00 0 0 0 0.00 0.00 42.00

43.00 Other General Service 18.00 0 0 0 0.00 0.00 43.00


MCRIF32 - 8.8.159.0 16 | Page


Date/Time Prepared:

Worksheet S-3

Part III

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Worksheet A

Line Number

Amount

Reported

Reclassificat

ion of

Salaries

(from

Worksheet

A-6)

Adjusted

Salaries

(col.2 ± col.

3)

Paid Hours

Related to

Salaries in

col. 4

Average

Hourly Wage

(col. 4 ÷

col. 5)

1.00 2.00 3.00 4.00 5.00 6.00

PART III - HOSPITAL WAGE INDEX SUMMARY

1.00 Net salaries (see

instructions)

87,258,707 0 87,258,707 3,123,959.36 27.93 1.00

2.00 Excluded area salaries (see

instructions)

32,547,837 49,736 32,597,573 746,261.99 43.68 2.00

3.00 Subtotal salaries (line 1

minus line 2)

54,710,870 -49,736 54,661,134 2,377,697.37 22.99 3.00

4.00 Subtotal other wages & related

costs (see inst.)

12,270,382 0 12,270,382 424,424.72 28.91 4.00

5.00 Subtotal wage-related costs

(see inst.)

14,455,209 0 14,455,209 0.00 26.45 5.00

6.00 Total (sum of lines 3 thru 5) 81,436,461 -49,736 81,386,725 2,802,122.09 29.04 6.00

7.00 Total overhead cost (see

instructions)

22,656,804 -49,736 22,607,068 1,083,060.51 20.87 7.00


MCRIF32 - 8.8.159.0 17 | Page


Date/Time Prepared:

Worksheet S-3

Part IV

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110HOSPITAL WAGE RELATED COSTS

Amount

Reported

1.00

PART IV - WAGE RELATED COSTS

Part A - Core List

RETIREMENT COST

1.00 401K Employer Contributions 0 1.00

2.00 Tax Sheltered Annuity (TSA) Employer Contribution 4,367,074 2.00

3.00 Nonqualified Defined Benefit Plan Cost (see instructions) 0 3.00

4.00 Qualified Defined Benefit Plan Cost (see instructions) 0 4.00

PLAN ADMINISTRATIVE COSTS (Paid to External Organization)

5.00 401K/TSA Plan Administration fees 0 5.00

6.00 Legal/Accounting/Management Fees-Pension Plan 0 6.00

7.00 Employee Managed Care Program Administration Fees 83,319 7.00

HEALTH AND INSURANCE COST

8.00 Health Insurance (Purchased or Self Funded) 9,143,865 8.00

9.00 Prescription Drug Plan 0 9.00

10.00 Dental, Hearing and Vision Plan 240,936 10.00

11.00 Life Insurance (If employee is owner or beneficiary) 118,166 11.00

12.00 Accident Insurance (If employee is owner or beneficiary) 0 12.00

13.00 Disability Insurance (If employee is owner or beneficiary) 475,209 13.00

14.00 Long-Term Care Insurance (If employee is owner or beneficiary) 0 14.00

15.00 'Workers' Compensation Insurance 581,979 15.00

16.00 Retirement Health Care Cost (Only current year, not the extraordinary accrual required by FASB 106.

Non cumulative portion)

0 16.00

TAXES

17.00 FICA-Employers Portion Only 6,443,476 17.00

18.00 Medicare Taxes - Employers Portion Only 66 18.00

19.00 Unemployment Insurance 96,821 19.00

20.00 State or Federal Unemployment Taxes 43,120 20.00

OTHER

21.00 Executive Deferred Compensation (Other Than Retirement Cost Reported on lines 1 through 4 above. (see

instructions))

0 21.00

22.00 Day Care Cost and Allowances 0 22.00

23.00 Tuition Reimbursement 37,500 23.00

24.00 Total Wage Related cost (Sum of lines 1 -23) 21,631,531 24.00

Part B - Other than Core Related Cost

25.00 OTHER WAGE RELATED COST 0 25.00


MCRIF32 - 8.8.159.0 18 | Page


Date/Time Prepared:

Worksheet S-3

Part V

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110HOSPITAL CONTRACT LABOR AND BENEFIT COST

Cost Center Description Contract

Labor

Benefit Cost

1.00 2.00

PART V - Contract Labor and Benefit Cost

Hospital and Hospital-Based Component Identification:

1.00 Total facility's contract labor and benefit cost 0 21,631,531 1.00

2.00 Hospital 0 20,159,079 2.00

3.00 Subprovider - IPF 0 236,768 3.00

4.00 Subprovider - IRF 0 158,616 4.00

5.00 Subprovider - (Other) 0 0 5.00

6.00 Swing Beds - SNF 0 0 6.00

7.00 Swing Beds - NF 0 0 7.00

8.00 Hospital-Based SNF 8.00

9.00 Hospital-Based NF 9.00

10.00 Hospital-Based OLTC 10.00

11.00 Hospital-Based HHA 0 191,453 11.00

12.00 Separately Certified ASC 12.00

13.00 Hospital-Based Hospice 0 207,432 13.00

14.00 Hospital-Based Health Clinic RHC 0 0 14.00

14.01 Hospital-Based Health Clinic RHC 1 0 394,323 14.01

14.02 Hospital-Based Health Clinic RHC 2 0 283,860 14.02

15.00 Hospital-Based Health Clinic FQHC 15.00

16.00 Hospital-Based-CMHC 16.00

17.00 Renal Dialysis 17.00

18.00 Other 0 0 18.00


MCRIF32 - 8.8.159.0 19 | Page


Date/Time Prepared:

Worksheet S-4

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Component CCN:267121

HOME HEALTH AGENCY STATISTICAL DATA

Home Health

Agency I

PPS

1.00

0.00 County CAPE GIRARDEAU 0.00

Title V Title XVIII Title XIX Other Total

1.00 2.00 3.00 4.00 5.00

HOME HEALTH AGENCY STATISTICAL DATA

1.00 Home Health Aide Hours 0 242 0 133 375 1.00

2.00 Unduplicated Census Count (see instructions) 0.00 317.00 23.00 183.00 523.00 2.00

Number of Employees (Full Time Equivalent)

Enter the number of hours in

your normal work week

Staff Contract Total

0 1.00 2.00 3.00

HOME HEALTH AGENCY - NUMBER OF EMPLOYEES

3.00 Administrator and Assistant Administrator(s) 40.00 0.00 0.00 0.00 3.00

4.00 Director(s) and Assistant Director(s) 1.00 0.00 1.00 4.00

5.00 Other Administrative Personnel 2.54 0.00 2.54 5.00

6.00 Direct Nursing Service 7.30 0.00 7.30 6.00

7.00 Nursing Supervisor 0.00 0.00 0.00 7.00

8.00 Physical Therapy Service 2.77 0.00 2.77 8.00

9.00 Physical Therapy Supervisor 0.00 0.00 0.00 9.00

10.00 Occupational Therapy Service 0.48 0.00 0.48 10.00

11.00 Occupational Therapy Supervisor 0.00 0.00 0.00 11.00

12.00 Speech Pathology Service 0.10 0.00 0.10 12.00

13.00 Speech Pathology Supervisor 0.00 0.00 0.00 13.00

14.00 Medical Social Service 0.67 0.00 0.67 14.00

15.00 Medical Social Service Supervisor 0.00 0.00 0.00 15.00

16.00 Home Health Aide 0.18 0.00 0.18 16.00

17.00 Home Health Aide Supervisor 0.00 0.00 0.00 17.00

18.00 DIETICIAN 0.00 0.00 0.00 18.00

HOME HEALTH AGENCY CBSA CODES

19.00 Enter in column 1 the number of CBSAs where

you provided services during the cost

reporting period.

3 19.00

20.00 List those CBSA code(s) in column 1 serviced

during this cost reporting period (line 20

contains the first code).

16020 20.00

20.01 50089 20.01

20.02 99926 20.02

Full Episodes

Without

Outliers

With Outliers LUPA Episodes PEP Only

Episodes

Total (cols.

1-4)

1.00 2.00 3.00 4.00 5.00

PPS ACTIVITY DATA

21.00 Skilled Nursing Visits 1,847 26 54 12 1,939 21.00

22.00 Skilled Nursing Visit Charges 275,665 3,881 8,060 4,179 291,785 22.00

23.00 Physical Therapy Visits 1,645 0 24 23 1,692 23.00

24.00 Physical Therapy Visit Charges 417,008 0 6,084 8,112 431,204 24.00

25.00 Occupational Therapy Visits 294 0 2 0 296 25.00

26.00 Occupational Therapy Visit Charges 74,529 0 507 0 75,036 26.00

27.00 Speech Pathology Visits 43 0 1 0 44 27.00

28.00 Speech Pathology Visit Charges 10,901 0 254 0 11,155 28.00

29.00 Medical Social Service Visits 36 2 1 0 39 29.00

30.00 Medical Social Service Visit Charges 5,769 321 160 0 6,250 30.00

31.00 Home Health Aide Visits 173 1 0 4 178 31.00

32.00 Home Health Aide Visit Charges 9,342 54 0 216 9,612 32.00

33.00 Total visits (sum of lines 21, 23, 25, 27,

29, and 31)

4,038 29 82 39 4,188 33.00

34.00 Other Charges 0 0 0 0 0 34.00

35.00 Total Charges (sum of lines 22, 24, 26, 28,

30, 32, and 34)

793,214 4,256 15,065 12,507 825,042 35.00

36.00 Total Number of Episodes (standard/non

outlier)

341 29 3 373 36.00

37.00 Total Number of Outlier Episodes 1 1 2 37.00

38.00 Total Non-Routine Medical Supply Charges 11,281 188 208 37 11,714 38.00


MCRIF32 - 8.8.159.0 20 | Page


Date/Time Prepared:

Worksheet S-8

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110


HOSPITAL-BASED RURAL HEALTH CLINIC/FEDERALLY QUALIFIED HEALTH CENTER

STATISTICAL DATA

Rural Health

Clinic (RHC) II

Cost

1.00

Clinic Address and Identification

1.00 Street 817 S MOUNT AUB 1.00

City State ZIP Code

1.00 2.00 3.00

2.00 City, State, ZIP Code, County 2.00CAPE GIRARDEAU MISSOURI 63701

1.00

3.00 FQHCs ONLY: Designation - Enter "R" for rural or "U" for urban 0 3.00

Grant Award Date

1.00 2.00

Source of Federal Funds

4.00 Community Health Center (Section 330(d), PHS Act) 0 4.00

5.00 Migrant Health Center (Section 329(d), PHS Act) 0 5.00

6.00 Health Services for the Homeless (Section 340(d), PHS Act) 0 6.00

7.00 Appalachian Regional Commission 0 7.00

8.00 Look-Alikes 0 8.00

9.00 OTHER (SPECIFY) 0 9.00

1.00 2.00

10.00 Does this facility operate as other than an RHC or FQHC? Enter "Y" for yes or "N" for

no in column 1. If yes, indicate number of other operations in column 2.(Enter in

subscripts of line 11 the type of other operation(s) and the operating hours.)

N 0 10.00

Sunday Monday Tuesday

from to from to from

1.00 2.00 3.00 4.00 5.00

Facility hours of operations (1)

11.00 Clinic 08:00 16:30 08:00 11.00

1.00 2.00

12.00 Have you received an approval for an exception to the productivity standard? N 12.00

13.00 Is this a consolidated cost report as defined in CMS Pub. 100-04, chapter 9, section

30.8? Enter "Y" for yes or "N" for no in column 1. If yes, enter in column 2 the

number of providers included in this report. List the names of all providers and

numbers below.

N 0 13.00

Provider name CCN number

1.00 2.00

14.00 Provider name, CCN number 14.00

Y/N V XVIII XIX Total Visits

1.00 2.00 3.00 4.00 5.00

15.00 Have you provided all or substantially all

GME cost? Enter "Y" for yes or "N" for no in

column 1. If yes, enter in columns 2, 3 and

4 the number of program visits performed by

Intern & Residents for titles V, XVIII, and

XIX, as applicable. Enter in column 5 the

number of total visits for this provider.

(see instructions)

15.00

County

4.00

2.00 City, State, ZIP Code, County 2.00CAPE GIRARDEAU

Tuesday Wednesday Thursday

to from to from to

6.00 7.00 8.00 9.00 10.00


11.00 Clinic 16:30 08:00 16:30 08:00 16:30 11.00


MCRIF32 - 8.8.159.0 21 | Page


Date/Time Prepared:

Worksheet S-8

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110



STATISTICAL DATA

Rural Health

Clinic (RHC) II

Cost

Friday Saturday

from to from to

11.00 12.00 13.00 14.00


11.00 Clinic 08:00 16:30 11.00


MCRIF32 - 8.8.159.0 22 | Page


Date/Time Prepared:

Worksheet S-8

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110



STATISTICAL DATA

Rural Health

Clinic (RHC) III

Cost

1.00

Clinic Address and Identification

1.00 Street 25 DOCTORS PARK 1.00

City State ZIP Code

1.00 2.00 3.00

2.00 City, State, ZIP Code, County 2.00CAPE GIRARDEAU MISSOURI 63703-4927

1.00

3.00 FQHCs ONLY: Designation - Enter "R" for rural or "U" for urban 0 3.00

Grant Award Date

1.00 2.00

Source of Federal Funds

4.00 Community Health Center (Section 330(d), PHS Act) 0 4.00

5.00 Migrant Health Center (Section 329(d), PHS Act) 0 5.00

6.00 Health Services for the Homeless (Section 340(d), PHS Act) 0 6.00

7.00 Appalachian Regional Commission 0 7.00

8.00 Look-Alikes 0 8.00

9.00 OTHER (SPECIFY) 0 9.00

1.00 2.00

10.00 Does this facility operate as other than an RHC or FQHC? Enter "Y" for yes or "N" for

no in column 1. If yes, indicate number of other operations in column 2.(Enter in

subscripts of line 11 the type of other operation(s) and the operating hours.)

N 0 10.00

Sunday Monday Tuesday

from to from to from

1.00 2.00 3.00 4.00 5.00


11.00 Clinic 08:00 16:30 08:00 11.00

1.00 2.00

12.00 Have you received an approval for an exception to the productivity standard? N 12.00

13.00 Is this a consolidated cost report as defined in CMS Pub. 100-04, chapter 9, section

30.8? Enter "Y" for yes or "N" for no in column 1. If yes, enter in column 2 the

number of providers included in this report. List the names of all providers and

numbers below.

N 0 13.00

Provider name CCN number

1.00 2.00

14.00 Provider name, CCN number 14.00

Y/N V XVIII XIX Total Visits

1.00 2.00 3.00 4.00 5.00

15.00 Have you provided all or substantially all

GME cost? Enter "Y" for yes or "N" for no in

column 1. If yes, enter in columns 2, 3 and

4 the number of program visits performed by

Intern & Residents for titles V, XVIII, and

XIX, as applicable. Enter in column 5 the

number of total visits for this provider.

(see instructions)

15.00

County

4.00

2.00 City, State, ZIP Code, County 2.00CAPE GIRARDEAU

Tuesday Wednesday Thursday

to from to from to

6.00 7.00 8.00 9.00 10.00


11.00 Clinic 16:30 08:00 16:30 08:00 16:30 11.00


MCRIF32 - 8.8.159.0 23 | Page


Date/Time Prepared:

Worksheet S-8

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110



STATISTICAL DATA

Rural Health

Clinic (RHC) III

Cost

Friday Saturday

from to from to

11.00 12.00 13.00 14.00


11.00 Clinic 08:00 16:30 11.00


MCRIF32 - 8.8.159.0 24 | Page


Date/Time Prepared:

Worksheet S-9

Parts I & II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110


HOSPITAL IDENTIFICATION DATA

Hospice I

Unduplicated

Days

Title XVIII Title XIX Title XVIII

Skilled

Nursing

Facility

Title XIX

Nursing

Facility

All Other Total (sum of

cols. 1, 2 &

5)

1.00 2.00 3.00 4.00 5.00 6.00

PART I - ENROLLMENT DAYS

1.00 Continuous Home Care 0 0 0 0 0 0 1.00

2.00 Routine Home Care 12,466 181 8,529 13 556 13,203 2.00

3.00 Inpatient Respite Care 75 7 0 0 4 86 3.00

4.00 General Inpatient Care 8 0 0 0 0 8 4.00

5.00 Total Hospice Days 12,549 188 8,529 13 560 13,297 5.00

Part II - CENSUS DATA

6.00 Number of Patients Receiving

Hospice Care

267 11 150 1 21 299 6.00

7.00 Total Number of Unduplicated

Continuous Care Hours Billable

to Medicare

0.00 0.00 7.00

8.00 Average Length of Stay (line

5/line 6)

47.00 17.09 56.86 13.00 26.67 44.47 8.00

9.00 Unduplicated Census Count 267 10 150 1 21 298 9.00


MCRIF32 - 8.8.159.0 25 | Page


Date/Time Prepared:

Worksheet S-10

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110HOSPITAL UNCOMPENSATED AND INDIGENT CARE DATA

1.00

Uncompensated and indigent care cost computation

1.00 Cost to charge ratio (Worksheet C, Part I line 202 column 3 divided by line 202 column 8) 0.249624 1.00

Medicaid (see instructions for each line)

2.00 Net revenue from Medicaid 22,257,043 2.00

3.00 Did you receive DSH or supplemental payments from Medicaid? Y 3.00

4.00 If line 3 is "yes", does line 2 include all DSH or supplemental payments from Medicaid? Y 4.00

5.00 If line 4 is "no", then enter DSH or supplemental payments from Medicaid 0 5.00

6.00 Medicaid charges 94,584,253 6.00

7.00 Medicaid cost (line 1 times line 6) 23,610,500 7.00

8.00 Difference between net revenue and costs for Medicaid program (line 7 minus sum of lines 2 and 5; if

< zero then enter zero)

1,353,457 8.00

State Children's Health Insurance Program (SCHIP) (see instructions for each line)

9.00 Net revenue from stand-alone SCHIP 0 9.00

10.00 Stand-alone SCHIP charges 0 10.00

11.00 Stand-alone SCHIP cost (line 1 times line 10) 0 11.00

12.00 Difference between net revenue and costs for stand-alone SCHIP (line 11 minus line 9; if < zero then

enter zero)

0 12.00

Other state or local government indigent care program (see instructions for each line)

13.00 Net revenue from state or local indigent care program (Not included on lines 2, 5 or 9) 0 13.00

14.00 Charges for patients covered under state or local indigent care program (Not included in lines 6 or

10)

0 14.00

15.00 State or local indigent care program cost (line 1 times line 14) 0 15.00

16.00 Difference between net revenue and costs for state or local indigent care program (line 15 minus line

13; if < zero then enter zero)

0 16.00

Uncompensated care (see instructions for each line)

17.00 Private grants, donations, or endowment income restricted to funding charity care 0 17.00

18.00 Government grants, appropriations or transfers for support of hospital operations 0 18.00

19.00 Total unreimbursed cost for Medicaid , SCHIP and state and local indigent care programs (sum of lines

8, 12 and 16)

1,353,457 19.00

Uninsured

patients

Insured

patients

Total (col. 1

+ col. 2)

1.00 2.00 3.00

20.00 Total initial obligation of patients approved for charity care (at full

charges excluding non-reimbursable cost centers) for the entire facility

9,275,034 2,663,811 11,938,845 20.00

21.00 Cost of initial obligation of patients approved for charity care (line 1

times line 20)

2,315,271 664,951 2,980,222 21.00

22.00 Partial payment by patients approved for charity care 0 0 0 22.00

23.00 Cost of charity care (line 21 minus line 22) 2,315,271 664,951 2,980,222 23.00

1.00

24.00 Does the amount in line 20 column 2 include charges for patient days beyond a length of stay limit

imposed on patients covered by Medicaid or other indigent care program?

N 24.00

25.00 If line 24 is "yes," charges for patient days beyond an indigent care program's length of stay limit 0 25.00

26.00 Total bad debt expense for the entire hospital complex (see instructions) 34,237,349 26.00

27.00 Medicare bad debts for the entire hospital complex (see instructions) 1,081,176 27.00

28.00 Non-Medicare and non-reimbursable Medicare bad debt expense (line 26 minus line 27) 33,156,173 28.00

29.00 Cost of non-Medicare and non-reimbursable Medicare bad debt expense (line 1 times line 28) 8,276,577 29.00

30.00 Cost of uncompensated care (line 23 column 3 plus line 29) 11,256,799 30.00

31.00 Total unreimbursed and uncompensated care cost (line 19 plus line 30) 12,610,256 31.00


MCRIF32 - 8.8.159.0 26 | Page


Date/Time Prepared:

Worksheet A

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110RECLASSIFICATION AND ADJUSTMENTS OF TRIAL BALANCE OF EXPENSES

Cost Center Description Salaries Other Total (col. 1

+ col. 2)

Reclassificat

ions (See

A-6)

Reclassified

Trial Balance

(col. 3 +-

col. 4)

1.00 2.00 3.00 4.00 5.00

GENERAL SERVICE COST CENTERS

1.00 00100 CAP REL COSTS-BLDG & FIXT 8,167,919 8,167,919 -7,870,291 297,628 1.00

1.01 00101 NEW CAP-REL CSTS-BLDGS & FIX #2 0 0 304,510 304,510 1.01



1.04 00104 NEW CAP-REL CSTS-BLDGS & FIX #5 0 0 0 0 1.04




1.08 00108 NEW CAP-REL CSTS-BLDGS & FIX #9 0 0 11,372,944 11,372,944 1.08



2.00 00200 CAP REL COSTS-MVBLE EQUIP 16,233,924 16,233,924 79,232 16,313,156 2.00

3.00 00300 OTHER CAP REL COSTS 0 0 0 0 3.00

4.00 00400 EMPLOYEE BENEFITS DEPARTMENT 415,208 12,488,958 12,904,166 -2,098,973 10,805,193 4.00

5.01 01160 COMMUNICATIONS 174,946 637,814 812,760 0 812,760 5.01

5.02 00550 DATA PROCESSING 2,047,119 4,733,171 6,780,290 0 6,780,290 5.02

5.03 00560 PURCHASING RECEIVING AND STORES 673,588 1,065,686 1,739,274 0 1,739,274 5.03

5.04 00570 ADMITTING 1,928,764 625,437 2,554,201 10,993 2,565,194 5.04

5.05 00580 CASHIERING/ACCOUNTS RECEIVABLE 1,862,917 3,085,167 4,948,084 0 4,948,084 5.05

5.06 00590 OTHER ADMINISTRATIVE & GENERAL 6,958,536 32,939,499 39,898,035 0 39,898,035 5.06

6.00 00600 MAINTENANCE & REPAIRS 1,945,663 1,678,659 3,624,322 0 3,624,322 6.00

7.00 00700 OPERATION OF PLANT 0 5,779,552 5,779,552 3,080 5,782,632 7.00

8.00 00800 LAUNDRY & LINEN SERVICE 0 30,520 30,520 0 30,520 8.00

9.00 00900 HOUSEKEEPING 1,958,009 1,515,505 3,473,514 0 3,473,514 9.00

10.00 01000 DIETARY 1,168,176 2,223,095 3,391,271 0 3,391,271 10.00

11.00 01100 CAFETERIA 0 0 0 0 0 11.00

12.00 01200 MAINTENANCE OF PERSONNEL 0 0 0 0 0 12.00

13.00 01300 NURSING ADMINISTRATION 2,706,479 1,538,754 4,245,233 -49,736 4,195,497 13.00

14.00 01400 CENTRAL SERVICES & SUPPLY 817,399 1,016,072 1,833,471 -111,410 1,722,061 14.00

15.00 01500 PHARMACY 0 0 0 0 0 15.00

16.00 01600 MEDICAL RECORDS & LIBRARY 0 0 0 0 0 16.00

17.00 01700 SOCIAL SERVICE 0 0 0 0 0 17.00

19.00 01900 NONPHYSICIAN ANESTHETISTS 0 0 0 0 0 19.00

20.00 02000 NURSING SCHOOL 1,613,783 620,685 2,234,468 0 2,234,468 20.00

20.01 02001 SCHOOL OF MEDICAL TECHNOLOGY 125,210 45,247 170,457 0 170,457 20.01

20.02 02002 SCHOOL OF SURGICAL TECHNOLOGY 48,894 21,151 70,045 0 70,045 20.02

20.03 02003 SCHOOL OF RADIOLOGICAL TECHNOLO 156,178 49,512 205,690 0 205,690 20.03

21.00 02100 I&R SERVICES-SALARY & FRINGES APPRV 0 0 0 0 0 21.00

22.00 02200 I&R SERVICES-OTHER PRGM COSTS APPRV 0 0 0 0 0 22.00

23.00 02300 PARAMEDICAL EDUCATION PROGRAM 0 0 0 0 0 23.00

INPATIENT ROUTINE SERVICE COST CENTERS

30.00 03000 ADULTS & PEDIATRICS 15,269,623 4,598,883 19,868,506 -1,486,870 18,381,636 30.00

33.01 03301 ADULT SPECIAL CARE 1,728,544 712,359 2,440,903 -289,456 2,151,447 33.01

34.01 03401 CARDIOTHORACIC ICU 1,176,956 375,501 1,552,457 -94,011 1,458,446 34.01

40.00 04000 SUBPROVIDER - IPF 1,276,177 321,483 1,597,660 61,005 1,658,665 40.00

41.00 04100 SUBPROVIDER - IRF 854,940 212,108 1,067,048 -5,372 1,061,676 41.00

43.00 04300 NURSERY 618,463 112,710 731,173 -27,273 703,900 43.00

ANCILLARY SERVICE COST CENTERS

50.00 05000 OPERATING ROOM 4,477,564 21,941,331 26,418,895 -18,566,715 7,852,180 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0 0 0 1,378,992 1,378,992 52.00

53.00 05300 ANESTHESIOLOGY 5,608,107 1,939,931 7,548,038 154,117 7,702,155 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 2,336,021 1,713,709 4,049,730 -795,907 3,253,823 54.00

54.01 05401 ULTRASOUND 478,610 186,515 665,125 -32,010 633,115 54.01

54.03 05403 CARDIOVASCULAR LAB 1,469,889 8,472,366 9,942,255 -6,452,225 3,490,030 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 1,328,268 946,117 2,274,385 -260,894 2,013,491 55.00

55.01 05501 CHEMOTHERAPY 525,561 188,060 713,621 81,480 795,101 55.01

56.01 05601 NUCLEAR MEDICINE 321,035 1,123,328 1,444,363 -653 1,443,710 56.01

57.00 05700 CT SCAN 530,377 581,864 1,112,241 -124,898 987,343 57.00

58.00 05800 MRI 335,198 250,514 585,712 -4,401 581,311 58.00

60.00 06000 LABORATORY 3,666,986 4,820,914 8,487,900 609,477 9,097,377 60.00

62.30 06250 BLOOD CLOTTING FACTORS FOR HEMOPH. 0 0 0 0 0 62.30

63.00 06300 BLOOD STORING, PROCESSING & TRANS. 745 860,678 861,423 37,798 899,221 63.00

65.00 06500 RESPIRATORY THERAPY 1,492,426 889,372 2,381,798 -31,685 2,350,113 65.00

66.00 06600 PHYSICAL THERAPY 808,337 118,965 927,302 -684 926,618 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 1,735,819 291,742 2,027,561 -175 2,027,386 66.01

66.02 06602 PHYSIATRY 0 0 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 209,647 25,654 235,301 -136 235,165 67.00

68.00 06800 SPEECH PATHOLOGY 154,951 19,527 174,478 0 174,478 68.00

69.01 06901 CV DIAGNOSTIC 688,781 678,224 1,367,005 51,635 1,418,640 69.01

69.02 06902 ELECTROPHYSIOLOGY LAB 0 0 0 0 0 69.02

70.01 07001 NEUROPHYSIOLOGY 549,948 231,314 781,262 -48,419 732,843 70.01


MCRIF32 - 8.8.159.0 27 | Page


Date/Time Prepared:

Worksheet A

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Cost Center Description Salaries Other Total (col. 1

+ col. 2)

Reclassificat

ions (See

A-6)

Reclassified

Trial Balance

(col. 3 +-

col. 4)

1.00 2.00 3.00 4.00 5.00

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 0 3,113 3,113 11,040,827 11,043,940 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0 0 0 16,846,024 16,846,024 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 2,397,492 16,949,593 19,347,085 100,567 19,447,652 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 387,897 59,048 446,945 -47 446,898 76.97

76.98 07698 HYPERBARIC OXYGEN THERAPY 0 0 0 0 0 76.98

76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99

OUTPATIENT SERVICE COST CENTERS

88.00 08800 RURAL HEALTH CLINIC 0 0 0 0 0 88.00

88.01 08801 RURAL HEALTH CLINIC II 2,125,400 496,434 2,621,834 0 2,621,834 88.01

88.02 08802 RURAL HEALTH CLINIC III 1,530,004 712,656 2,242,660 0 2,242,660 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 819,549 234,883 1,054,432 67,613 1,122,045 90.01

90.02 09002 DIABETES CENTER 161,555 27,116 188,671 0 188,671 90.02

91.00 09100 EMERGENCY 7,931,343 3,369,117 11,300,460 201,878 11,502,338 91.00

91.01 09101 G.I. LABORATORY 524,174 584,597 1,108,771 -210,192 898,579 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 92.00

OTHER REIMBURSABLE COST CENTERS

101.00 10100 HOME HEALTH AGENCY 1,031,931 277,763 1,309,694 24,868 1,334,562 101.00

SPECIAL PURPOSE COST CENTERS

113.00 11300 INTEREST EXPENSE 6,445,015 6,445,015 -6,404,064 40,951 113.00

116.00 11600 HOSPICE 1,118,060 894,783 2,012,843 24,868 2,037,711 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 90,271,247 176,163,614 266,434,861 3,080 266,437,941 118.00

NONREIMBURSABLE COST CENTERS

190.00 19000 GIFT, FLOWER, COFFEE SHOP & CANTEEN 0 0 0 0 0 190.00

191.01 19101 RESPITE CARE 0 0 0 0 0 191.01

193.01 19301 VENDING MACHINES 0 0 0 0 0 193.01

193.02 19302 SUNSET GUEST HOUSE 0 0 0 0 0 193.02

193.03 19303 LACEYS RESTAURANT 0 11,802 11,802 0 11,802 193.03

193.04 19304 COMMUNITY WELLNESS 2,126 178,051 180,177 0 180,177 193.04

193.05 19305 HOME INFUSION 0 0 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 23,922,595 6,841,880 30,764,475 -3,080 30,761,395 193.06

193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 518,955 4,760,613 5,279,568 0 5,279,568 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 772,731 3,021,558 3,794,289 0 3,794,289 193.11

193.13 19313 HEALTHPOINT 1,075,645 701,329 1,776,974 0 1,776,974 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14

194.00 07950 JAZZMANS RESTAURANT 30,612 14,341 44,953 0 44,953 194.00

194.01 07951 FOUNDATION OFFICE 0 613 613 0 613 194.01

200.00 TOTAL (SUM OF LINES 118-199) 116,593,911 191,693,801 308,287,712 0 308,287,712 200.00


MCRIF32 - 8.8.159.0 28 | Page


Date/Time Prepared:

Worksheet A

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Cost Center Description Adjustments

(See A-8)

Net Expenses

For

Allocation

6.00 7.00


1.00 00100 CAP REL COSTS-BLDG & FIXT -20,229 277,399 1.00

1.01 00101 NEW CAP-REL CSTS-BLDGS & FIX #2 0 304,510 1.01



1.04 00104 NEW CAP-REL CSTS-BLDGS & FIX #5 0 0 1.04



1.07 00107 NEW CAP-REL CSTS-BLDGS & FIX #8 -16,882 852,103 1.07

1.08 00108 NEW CAP-REL CSTS-BLDGS & FIX #9 -85,155 11,287,789 1.08



2.00 00200 CAP REL COSTS-MVBLE EQUIP -355,203 15,957,953 2.00

3.00 00300 OTHER CAP REL COSTS 0 0 3.00

4.00 00400 EMPLOYEE BENEFITS DEPARTMENT -4,085,582 6,719,611 4.00

5.01 01160 COMMUNICATIONS -272,362 540,398 5.01

5.02 00550 DATA PROCESSING -1,866,437 4,913,853 5.02

5.03 00560 PURCHASING RECEIVING AND STORES 5,095 1,744,369 5.03

5.04 00570 ADMITTING -89,182 2,476,012 5.04

5.05 00580 CASHIERING/ACCOUNTS RECEIVABLE -967,369 3,980,715 5.05

5.06 00590 OTHER ADMINISTRATIVE & GENERAL -7,383,533 32,514,502 5.06

6.00 00600 MAINTENANCE & REPAIRS -204,894 3,419,428 6.00

7.00 00700 OPERATION OF PLANT -1,043,893 4,738,739 7.00

8.00 00800 LAUNDRY & LINEN SERVICE 0 30,520 8.00

9.00 00900 HOUSEKEEPING -81,074 3,392,440 9.00

10.00 01000 DIETARY -672,722 2,718,549 10.00

11.00 01100 CAFETERIA 0 0 11.00

12.00 01200 MAINTENANCE OF PERSONNEL 0 0 12.00

13.00 01300 NURSING ADMINISTRATION -230,570 3,964,927 13.00

14.00 01400 CENTRAL SERVICES & SUPPLY 0 1,722,061 14.00

15.00 01500 PHARMACY 0 0 15.00

16.00 01600 MEDICAL RECORDS & LIBRARY 0 0 16.00

17.00 01700 SOCIAL SERVICE 0 0 17.00

19.00 01900 NONPHYSICIAN ANESTHETISTS 0 0 19.00

20.00 02000 NURSING SCHOOL -2,234,468 0 20.00

20.01 02001 SCHOOL OF MEDICAL TECHNOLOGY -155,520 14,937 20.01

20.02 02002 SCHOOL OF SURGICAL TECHNOLOGY -70,045 0 20.02

20.03 02003 SCHOOL OF RADIOLOGICAL TECHNOLO -205,690 0 20.03

21.00 02100 I&R SERVICES-SALARY & FRINGES APPRV 0 0 21.00

22.00 02200 I&R SERVICES-OTHER PRGM COSTS APPRV 0 0 22.00

23.00 02300 PARAMEDICAL EDUCATION PROGRAM 0 0 23.00


30.00 03000 ADULTS & PEDIATRICS -5,648,071 12,733,565 30.00

33.01 03301 ADULT SPECIAL CARE 0 2,151,447 33.01

34.01 03401 CARDIOTHORACIC ICU 0 1,458,446 34.01

40.00 04000 SUBPROVIDER - IPF -633,925 1,024,740 40.00

41.00 04100 SUBPROVIDER - IRF -81,170 980,506 41.00

43.00 04300 NURSERY -6,000 697,900 43.00


50.00 05000 OPERATING ROOM -69,996 7,782,184 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0 1,378,992 52.00

53.00 05300 ANESTHESIOLOGY -7,310,855 391,300 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC -3,366 3,250,457 54.00

54.01 05401 ULTRASOUND 0 633,115 54.01

54.03 05403 CARDIOVASCULAR LAB -114,663 3,375,367 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC -54,379 1,959,112 55.00

55.01 05501 CHEMOTHERAPY 0 795,101 55.01

56.01 05601 NUCLEAR MEDICINE -1,000 1,442,710 56.01

57.00 05700 CT SCAN 0 987,343 57.00

58.00 05800 MRI 0 581,311 58.00

60.00 06000 LABORATORY -432,243 8,665,134 60.00

62.30 06250 BLOOD CLOTTING FACTORS FOR HEMOPH. 0 0 62.30

63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0 899,221 63.00

65.00 06500 RESPIRATORY THERAPY -2 2,350,111 65.00

66.00 06600 PHYSICAL THERAPY 0 926,618 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0 2,027,386 66.01

66.02 06602 PHYSIATRY 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 0 235,165 67.00

68.00 06800 SPEECH PATHOLOGY 0 174,478 68.00

69.01 06901 CV DIAGNOSTIC -4,422 1,414,218 69.01

69.02 06902 ELECTROPHYSIOLOGY LAB 0 0 69.02

70.01 07001 NEUROPHYSIOLOGY -84,445 648,398 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT -119 11,043,821 71.00


MCRIF32 - 8.8.159.0 29 | Page


Date/Time Prepared:

Worksheet A

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Cost Center Description Adjustments

(See A-8)

Net Expenses

For

Allocation

6.00 7.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0 16,846,024 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS -633,994 18,813,658 73.00

76.00 03950 CARDIAC REHAB 0 0 76.00

76.97 07697 CARDIAC REHABILITATION -134,440 312,458 76.97

76.98 07698 HYPERBARIC OXYGEN THERAPY 0 0 76.98

76.99 07699 LITHOTRIPSY 0 0 76.99


88.00 08800 RURAL HEALTH CLINIC 0 0 88.00

88.01 08801 RURAL HEALTH CLINIC II -8,176 2,613,658 88.01

88.02 08802 RURAL HEALTH CLINIC III -5,524 2,237,136 88.02

90.01 09001 HYPERBARIC WOUND CLINIC -587,967 534,078 90.01

90.02 09002 DIABETES CENTER 0 188,671 90.02

91.00 09100 EMERGENCY -6,618,955 4,883,383 91.00

91.01 09101 G.I. LABORATORY 0 898,579 91.01



101.00 10100 HOME HEALTH AGENCY -1,164 1,333,398 101.00


113.00 11300 INTEREST EXPENSE -40,951 0 113.00

116.00 11600 HOSPICE -223,800 1,813,911 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) -42,735,342 223,702,599 118.00


190.00 19000 GIFT, FLOWER, COFFEE SHOP & CANTEEN 0 0 190.00

191.01 19101 RESPITE CARE 0 0 191.01

193.01 19301 VENDING MACHINES 0 0 193.01

193.02 19302 SUNSET GUEST HOUSE 0 0 193.02

193.03 19303 LACEYS RESTAURANT 0 11,802 193.03

193.04 19304 COMMUNITY WELLNESS 0 180,177 193.04

193.05 19305 HOME INFUSION 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC -638,040 30,123,355 193.06

193.07 19307 GENERATIONS 0 0 193.07

193.08 19308 RETAIL PHARMACY 0 5,279,568 193.08

193.09 19309 OUTREACH LAB 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 193.10

193.11 19311 MARKETING -1,077,599 2,716,690 193.11

193.13 19313 HEALTHPOINT 0 1,776,974 193.13

193.14 19314 DOCTORS PARK 0 0 193.14

194.00 07950 JAZZMANS RESTAURANT 0 44,953 194.00

194.01 07951 FOUNDATION OFFICE 0 613 194.01

200.00 TOTAL (SUM OF LINES 118-199) -44,450,981 263,836,731 200.00


MCRIF32 - 8.8.159.0 30 | Page


Date/Time Prepared:

Worksheet A-6

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110RECLASSIFICATIONS

Increases

Cost Center Line # Salary Other

2.00 3.00 4.00 5.00

A - TO RECLASS BUILDING DEPRECIATION

1.00 NEW CAP-REL CSTS-BLDGS & FIX

#2

1.01 0 304,510 1.00


#3

1.02 0 603,866 2.00


#4

1.03 0 336,528 3.00


#6

1.05 0 217,366 4.00


#7

1.06 0 490,924 5.00


#8

1.07 0 868,985 6.00


#9

1.08 0 5,048,112 7.00

TOTALS 0 7,870,291

B - TO RECLASS INTEREST EXPENSE


#9

1.08 0 6,324,832 1.00

2.00 CAP REL COSTS-MVBLE EQUIP 2.00 0 79,232 2.00

TOTALS 0 6,404,064

D - TO RECLASS SUPPLY EXPENSE

1.00 MEDICAL SUPPLIES CHARGED TO

PATIENT

71.00 0 11,040,827 1.00

2.00 0.00 0 0 2.00

3.00 0.00 0 0 3.00

4.00 0.00 0 0 4.00

5.00 0.00 0 0 5.00

6.00 0.00 0 0 6.00

7.00 0.00 0 0 7.00

8.00 0.00 0 0 8.00

9.00 0.00 0 0 9.00

10.00 0.00 0 0 10.00

11.00 0.00 0 0 11.00

12.00 0.00 0 0 12.00

13.00 0.00 0 0 13.00

14.00 0.00 0 0 14.00

15.00 0.00 0 0 15.00

16.00 0.00 0 0 16.00

17.00 0.00 0 0 17.00

18.00 0.00 0 0 18.00

19.00 0.00 0 0 19.00

20.00 0.00 0 0 20.00

21.00 0.00 0 0 21.00

22.00 0.00 0 0 22.00

23.00 0.00 0 0 23.00

24.00 0.00 0 0 24.00

25.00 0.00 0 0 25.00

26.00 0.00 0 0 26.00

27.00 0.00 0 0 27.00

28.00 0.00 0 0 28.00

29.00 0.00 0 0 29.00

30.00 0.00 0 0 30.00

TOTALS 0 11,040,827

E - TO RECLASS IMPLANTABLES

1.00 IMPL. DEV. CHARGED TO

PATIENTS

72.00 0 19,031,611 1.00

2.00 0.00 0 0 2.00

3.00 0.00 0 0 3.00

4.00 0.00 0 0 4.00

5.00 0.00 0 0 5.00

6.00 0.00 0 0 6.00

7.00 0.00 0 0 7.00

8.00 0.00 0 0 8.00

TOTALS 0 19,031,611

F - TO RECLASS HHA ADMIN COST

1.00 HOME HEALTH AGENCY 101.00 24,868 0 1.00

2.00 HOSPICE 116.00 24,868 0 2.00

TOTALS 49,736 0

G - TO RECLASS ADMIN TO APPROP DEPT

1.00 CV DIAGNOSTIC 69.01 39,896 18,844 1.00

TOTALS 39,896 18,844


MCRIF32 - 8.8.159.0 31 | Page


Date/Time Prepared:

Worksheet A-6

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Increases

Cost Center Line # Salary Other

2.00 3.00 4.00 5.00

H - TO RECLASS ADMIN TO APPROP DEPT

1.00 CHEMOTHERAPY 55.01 111,602 34,614 1.00

TOTALS 111,602 34,614

I - TO RECLASS WEST CAMPUS MOB TO PLANT

1.00 OPERATION OF PLANT 7.00 0 3,080 1.00

TOTALS 0 3,080

J - TO RECLASS LABOR/ DELIVERY EXPENSE

1.00 DELIVERY ROOM & LABOR ROOM 52.00 1,063,846 315,146 1.00

TOTALS 1,063,846 315,146

K - RECLASS PHYSICIAN BENEFITS

1.00 ADMITTING 5.04 0 10,993 1.00

2.00 ADULTS & PEDIATRICS 30.00 0 504,344 2.00

3.00 SUBPROVIDER - IPF 40.00 0 62,073 3.00

4.00 SUBPROVIDER - IRF 41.00 0 2,731 4.00

5.00 ANESTHESIOLOGY 53.00 0 758,324 5.00

6.00 CARDIOVASCULAR LAB 54.03 0 13,632 6.00

7.00 NEUROPHYSIOLOGY 70.01 0 9,891 7.00

8.00 HYPERBARIC WOUND CLINIC 90.01 0 70,834 8.00

9.00 EMERGENCY 91.00 0 666,151 9.00

TOTALS 0 2,098,973

L - TO RECLASS INVENTORY ADJMT

1.00 OPERATING ROOM 50.00 0 1,347,567 1.00

2.00 CARDIOVASCULAR LAB 54.03 0 83,926 2.00

3.00 LABORATORY 60.00 0 612,368 3.00

4.00 BLOOD STORING, PROCESSING &

TRANS.

63.00 0 42,321 4.00

5.00 DRUGS CHARGED TO PATIENTS 73.00 0 103,882 5.00

TOTALS 0 2,190,064

500.00 Grand Total: Increases 1,265,080 49,007,514 500.00


MCRIF32 - 8.8.159.0 32 | Page


Date/Time Prepared:

Worksheet A-6

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Decreases

Cost Center Line # Salary Other Wkst. A-7 Ref.

6.00 7.00 8.00 9.00 10.00

A - TO RECLASS BUILDING DEPRECIATION

1.00 CAP REL COSTS-BLDG & FIXT 1.00 0 7,870,291 9 1.00

2.00 0.00 0 0 9 2.00

3.00 0.00 0 0 9 3.00

4.00 0.00 0 0 9 4.00

5.00 0.00 0 0 9 5.00

6.00 0.00 0 0 9 6.00

7.00 0.00 0 0 9 7.00

TOTALS 0 7,870,291

B - TO RECLASS INTEREST EXPENSE

1.00 INTEREST EXPENSE 113.00 0 6,404,064 11 1.00

2.00 0.00 0 0 11 2.00

TOTALS 0 6,404,064

D - TO RECLASS SUPPLY EXPENSE

1.00 CENTRAL SERVICES & SUPPLY 14.00 0 111,410 0 1.00

2.00 ADULTS & PEDIATRICS 30.00 0 609,426 0 2.00

3.00 ADULT SPECIAL CARE 33.01 0 289,456 0 3.00

4.00 CARDIOTHORACIC ICU 34.01 0 94,011 0 4.00

5.00 SUBPROVIDER - IPF 40.00 0 1,068 0 5.00

6.00 SUBPROVIDER - IRF 41.00 0 8,103 0 6.00

7.00 NURSERY 43.00 0 27,273 0 7.00

8.00 OPERATING ROOM 50.00 0 5,638,083 0 8.00

9.00 ANESTHESIOLOGY 53.00 0 599,730 0 9.00

10.00 RADIOLOGY-DIAGNOSTIC 54.00 0 781,338 0 10.00

11.00 ULTRASOUND 54.01 0 31,406 0 11.00

12.00 CARDIOVASCULAR LAB 54.03 0 1,759,232 0 12.00

13.00 RADIOLOGY-THERAPEUTIC 55.00 0 114,678 0 13.00

14.00 CHEMOTHERAPY 55.01 0 64,736 0 14.00

15.00 NUCLEAR MEDICINE 56.01 0 653 0 15.00

16.00 CT SCAN 57.00 0 124,898 0 16.00

17.00 MRI 58.00 0 4,401 0 17.00

18.00 LABORATORY 60.00 0 2,891 0 18.00

19.00 BLOOD STORING, PROCESSING &

TRANS.

63.00 0 4,523 0 19.00

20.00 RESPIRATORY THERAPY 65.00 0 31,685 0 20.00

21.00 PHYSICAL THERAPY 66.00 0 684 0 21.00

22.00 SOUTHEAST OUTPATIENT REHAB 66.01 0 175 0 22.00

23.00 OCCUPATIONAL THERAPY 67.00 0 136 0 23.00

24.00 CV DIAGNOSTIC 69.01 0 6,497 0 24.00

25.00 NEUROPHYSIOLOGY 70.01 0 58,310 0 25.00

26.00 DRUGS CHARGED TO PATIENTS 73.00 0 3,315 0 26.00

27.00 CARDIAC REHABILITATION 76.97 0 47 0 27.00

28.00 HYPERBARIC WOUND CLINIC 90.01 0 3,221 0 28.00

29.00 EMERGENCY 91.00 0 463,962 0 29.00

30.00 G.I. LABORATORY 91.01 0 205,479 0 30.00

TOTALS 0 11,040,827

E - TO RECLASS IMPLANTABLES

1.00 ADULTS & PEDIATRICS 30.00 0 2,796 0 1.00

2.00 OPERATING ROOM 50.00 0 14,276,199 0 2.00

3.00 RADIOLOGY-DIAGNOSTIC 54.00 0 14,569 0 3.00

4.00 ULTRASOUND 54.01 0 604 0 4.00

5.00 CARDIOVASCULAR LAB 54.03 0 4,731,811 0 5.00

6.00 CV DIAGNOSTIC 69.01 0 608 0 6.00

7.00 EMERGENCY 91.00 0 311 0 7.00

8.00 G.I. LABORATORY 91.01 0 4,713 0 8.00

TOTALS 0 19,031,611

F - TO RECLASS HHA ADMIN COST

1.00 NURSING ADMINISTRATION 13.00 49,736 0 0 1.00

2.00 0.00 0 0 0 2.00

TOTALS 49,736 0

G - TO RECLASS ADMIN TO APPROP DEPT

1.00 CARDIOVASCULAR LAB 54.03 39,896 18,844 0 1.00

TOTALS 39,896 18,844

H - TO RECLASS ADMIN TO APPROP DEPT

1.00 RADIOLOGY-THERAPEUTIC 55.00 111,602 34,614 0 1.00

TOTALS 111,602 34,614

I - TO RECLASS WEST CAMPUS MOB TO PLANT

1.00 SE HOSP PHYSICIANS LLC 193.06 0 3,080 0 1.00

TOTALS 0 3,080

J - TO RECLASS LABOR/ DELIVERY EXPENSE

1.00 ADULTS & PEDIATRICS 30.00 1,063,846 315,146 0 1.00

TOTALS 1,063,846 315,146


MCRIF32 - 8.8.159.0 33 | Page


Date/Time Prepared:

Worksheet A-6

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Decreases

Cost Center Line # Salary Other Wkst. A-7 Ref.

6.00 7.00 8.00 9.00 10.00

K - RECLASS PHYSICIAN BENEFITS

1.00 EMPLOYEE BENEFITS DEPARTMENT 4.00 0 2,098,973 0 1.00

2.00 0.00 0 0 0 2.00

3.00 0.00 0 0 0 3.00

4.00 0.00 0 0 0 4.00

5.00 0.00 0 0 0 5.00

6.00 0.00 0 0 0 6.00

7.00 0.00 0 0 0 7.00

8.00 0.00 0 0 0 8.00

9.00 0.00 0 0 0 9.00

TOTALS 0 2,098,973

L - TO RECLASS INVENTORY ADJMT

1.00 IMPL. DEV. CHARGED TO

PATIENTS

72.00 0 2,185,587 0 1.00

2.00 ANESTHESIOLOGY 53.00 0 4,477 0 2.00

3.00 0.00 0 0 0 3.00

4.00 0.00 0 0 0 4.00

5.00 0.00 0 0 0 5.00

TOTALS 0 2,190,064

500.00 Grand Total: Decreases 1,265,080 49,007,514 500.00


MCRIF32 - 8.8.159.0 34 | Page


Date/Time Prepared:

Worksheet A-7

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110RECONCILIATION OF CAPITAL COSTS CENTERS

Acquisitions

Beginning

Balances

Purchases Donation Total Disposals and

Retirements

1.00 2.00 3.00 4.00 5.00

PART I - ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCES

1.00 Land 17,714,791 0 0 0 16,350 1.00

2.00 Land Improvements 13,095,472 2,519 0 2,519 0 2.00

3.00 Buildings and Fixtures 197,547,335 2,899,266 0 2,899,266 142,068 3.00

4.00 Building Improvements 0 0 0 0 0 4.00

5.00 Fixed Equipment 0 0 0 0 0 5.00

6.00 Movable Equipment 70,987,878 59,132,217 0 59,132,217 2,766,058 6.00

7.00 HIT designated Assets 8,700,914 1,069,181 0 1,069,181 0 7.00

8.00 Subtotal (sum of lines 1-7) 308,046,390 63,103,183 0 63,103,183 2,924,476 8.00

9.00 Reconciling Items 0 0 0 0 0 9.00

10.00 Total (line 8 minus line 9) 308,046,390 63,103,183 0 63,103,183 2,924,476 10.00

Ending

Balance

Fully

Depreciated

Assets

6.00 7.00

PART I - ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCES

1.00 Land 17,698,441 0 1.00

2.00 Land Improvements 13,097,991 0 2.00

3.00 Buildings and Fixtures 200,304,533 0 3.00

4.00 Building Improvements 0 0 4.00

5.00 Fixed Equipment 0 0 5.00

6.00 Movable Equipment 127,354,037 0 6.00

7.00 HIT designated Assets 9,770,095 0 7.00

8.00 Subtotal (sum of lines 1-7) 368,225,097 0 8.00

9.00 Reconciling Items 0 0 9.00

10.00 Total (line 8 minus line 9) 368,225,097 0 10.00


MCRIF32 - 8.8.159.0 35 | Page


Date/Time Prepared:

Worksheet A-7

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


SUMMARY OF CAPITAL

Cost Center Description Depreciation Lease Interest Insurance

(see

instructions)

Taxes (see

instructions)

9.00 10.00 11.00 12.00 13.00

PART II - RECONCILIATION OF AMOUNTS FROM WORKSHEET A, COLUMN 2, LINES 1 and 2

1.00 CAP REL COSTS-BLDG & FIXT 8,167,919 0 0 0 0 1.00

1.01 NEW CAP-REL CSTS-BLDGS & FIX #2 0 0 0 0 0 1.01










2.00 CAP REL COSTS-MVBLE EQUIP 16,233,924 0 0 0 0 2.00

3.00 Total (sum of lines 1-2) 24,401,843 0 0 0 0 3.00

SUMMARY OF CAPITAL

Cost Center Description Other

Capital-Relat

ed Costs (see

instructions)

Total (1)

(sum of cols.

9 through 14)

14.00 15.00

PART II - RECONCILIATION OF AMOUNTS FROM WORKSHEET A, COLUMN 2, LINES 1 and 2

1.00 CAP REL COSTS-BLDG & FIXT 0 8,167,919 1.00

1.01 NEW CAP-REL CSTS-BLDGS & FIX #2 0 0 1.01










2.00 CAP REL COSTS-MVBLE EQUIP 0 16,233,924 2.00

3.00 Total (sum of lines 1-2) 0 24,401,843 3.00


MCRIF32 - 8.8.159.0 36 | Page


Date/Time Prepared:

Worksheet A-7

Part III

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


COMPUTATION OF RATIOS ALLOCATION OF OTHER CAPITAL

Cost Center Description Gross Assets Capitalized

Leases

Gross Assets

for Ratio

(col. 1 -

col. 2)

Ratio (see

instructions)

Insurance

1.00 2.00 3.00 4.00 5.00

PART III - RECONCILIATION OF CAPITAL COSTS CENTERS

1.00 CAP REL COSTS-BLDG & FIXT 231,100,965 0 231,100,965 0.627608 0 1.00

1.01 NEW CAP-REL CSTS-BLDGS & FIX #2 0 0 0 0.000000 0 1.01










2.00 CAP REL COSTS-MVBLE EQUIP 137,124,132 0 137,124,132 0.372392 0 2.00

3.00 Total (sum of lines 1-2) 368,225,097 0 368,225,097 1.000000 0 3.00

ALLOCATION OF OTHER CAPITAL SUMMARY OF CAPITAL

Cost Center Description Taxes Other

Capital-Relat

ed Costs

Total (sum of

cols. 5

through 7)

Depreciation Lease

6.00 7.00 8.00 9.00 10.00


1.00 CAP REL COSTS-BLDG & FIXT 0 0 0 277,399 0 1.00

1.01 NEW CAP-REL CSTS-BLDGS & FIX #2 0 0 0 304,510 0 1.01







1.08 NEW CAP-REL CSTS-BLDGS & FIX #9 0 0 0 5,048,112 0 1.08



2.00 CAP REL COSTS-MVBLE EQUIP 0 0 0 15,885,007 0 2.00

3.00 Total (sum of lines 1-2) 0 0 0 24,032,697 0 3.00

SUMMARY OF CAPITAL

Cost Center Description Interest Insurance

(see

instructions)

Taxes (see

instructions)

Other

Capital-Relat

ed Costs (see

instructions)

Total (2)

(sum of cols.

9 through 14)

11.00 12.00 13.00 14.00 15.00


1.00 CAP REL COSTS-BLDG & FIXT 0 0 0 0 277,399 1.00

1.01 NEW CAP-REL CSTS-BLDGS & FIX #2 0 0 0 0 304,510 1.01






1.07 NEW CAP-REL CSTS-BLDGS & FIX #8 -16,882 0 0 0 852,103 1.07

1.08 NEW CAP-REL CSTS-BLDGS & FIX #9 6,239,677 0 0 0 11,287,789 1.08



2.00 CAP REL COSTS-MVBLE EQUIP 72,946 0 0 0 15,957,953 2.00

3.00 Total (sum of lines 1-2) 6,295,741 0 0 0 30,328,438 3.00


MCRIF32 - 8.8.159.0 37 | Page


Date/Time Prepared:

Worksheet A-8

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110ADJUSTMENTS TO EXPENSES

Expense Classification on Worksheet A

To/From Which the Amount is to be Adjusted

Cost Center Description Basis/Code

(2)

Amount Cost Center Line # Wkst. A-7

Ref.

1.00 2.00 3.00 4.00 5.00

1.00 Investment income - CAP REL

COSTS-BLDG & FIXT (chapter 2)

0 CAP REL COSTS-BLDG & FIXT 1.00 0 1.00

1.01 Investment income - NEW

CAP-REL CSTS-BLDGS & FIX #2

(chapter 2)

0 NEW CAP-REL CSTS-BLDGS & FIX

#2

1.01 0 1.01



(chapter 2)


#3

1.02 0 1.02



(chapter 2)


#4

1.03 0 1.03



(chapter 2)


#5

1.04 0 1.04



(chapter 2)


#6

1.05 0 1.05



(chapter 2)


#7

1.06 0 1.06



(chapter 2)

B -16,882 NEW CAP-REL CSTS-BLDGS & FIX

#8

1.07 11 1.07



(chapter 2)


#9

1.08 0 1.08



(chapter 2)


#1

1.09 0 1.09



(chapter 2)


#1

1.10 0 1.10

2.00 Investment income - CAP REL

COSTS-MVBLE EQUIP (chapter 2)

0 CAP REL COSTS-MVBLE EQUIP 2.00 0 2.00

3.00 Investment income - other

(chapter 2)

0 0.00 0 3.00

4.00 Trade, quantity, and time

discounts (chapter 8)

0 0.00 0 4.00

5.00 Refunds and rebates of

expenses (chapter 8)

0 0.00 0 5.00

6.00 Rental of provider space by

suppliers (chapter 8)

0 0.00 0 6.00

7.00 Telephone services (pay

stations excluded) (chapter

21)

A -51,094 COMMUNICATIONS 5.01 0 7.00

8.00 Television and radio service

(chapter 21)

0 0.00 0 8.00

9.00 Parking lot (chapter 21) 0 0.00 0 9.00

10.00 Provider-based physician

adjustment

A-8-2 -20,417,924 0 10.00

11.00 Sale of scrap, waste, etc.

(chapter 23)

0 0.00 0 11.00

12.00 Related organization

transactions (chapter 10)

A-8-1 -12,242,787 0 12.00

13.00 Laundry and linen service 0 0.00 0 13.00

14.00 Cafeteria-employees and guests B -614,987 DIETARY 10.00 0 14.00

15.00 Rental of quarters to employee

and others

0 0.00 0 15.00

16.00 Sale of medical and surgical

supplies to other than

patients

0 0.00 0 16.00

17.00 Sale of drugs to other than

patients

B -8,050 DRUGS CHARGED TO PATIENTS 73.00 0 17.00

18.00 Sale of medical records and

abstracts

0 0.00 0 18.00

19.00 Nursing school (tuition, fees,

books, etc.)

B -2,234,468 NURSING SCHOOL 20.00 0 19.00


MCRIF32 - 8.8.159.0 38 | Page


Date/Time Prepared:

Worksheet A-8

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015





(2)


Ref.

1.00 2.00 3.00 4.00 5.00

20.00 Vending machines B -12,108 DIETARY 10.00 0 20.00

21.00 Income from imposition of

interest, finance or penalty

charges (chapter 21)

0 0.00 0 21.00

22.00 Interest expense on Medicare

overpayments and borrowings to

repay Medicare overpayments

0 0.00 0 22.00

23.00 Adjustment for respiratory

therapy costs in excess of

limitation (chapter 14)

A-8-3 0 RESPIRATORY THERAPY 65.00 23.00

24.00 Adjustment for physical



A-8-3 0 PHYSICAL THERAPY 66.00 24.00

25.00 Utilization review -

physicians' compensation

(chapter 21)

0 *** Cost Center Deleted *** 114.00 25.00

26.00 Depreciation - CAP REL

COSTS-BLDG & FIXT

0 CAP REL COSTS-BLDG & FIXT 1.00 0 26.00

26.01 Depreciation - NEW CAP-REL

CSTS-BLDGS & FIX #2


#2

1.01 0 26.01


CSTS-BLDGS & FIX #3


#3

1.02 0 26.02


CSTS-BLDGS & FIX #4


#4

1.03 0 26.03


CSTS-BLDGS & FIX #5


#5

1.04 0 26.04


CSTS-BLDGS & FIX #6


#6

1.05 0 26.05


CSTS-BLDGS & FIX #7


#7

1.06 0 26.06


CSTS-BLDGS & FIX #8


#8

1.07 0 26.07


CSTS-BLDGS & FIX #9


#9

1.08 0 26.08


CSTS-BLDGS & FIX #1


#1

1.09 0 26.09


CSTS-BLDGS & FIX #1


#1

1.10 0 26.10

27.00 Depreciation - CAP REL

COSTS-MVBLE EQUIP

A -6,286 CAP REL COSTS-MVBLE EQUIP 2.00 11 27.00

28.00 Non-physician Anesthetist 0 NONPHYSICIAN ANESTHETISTS 19.00 28.00

29.00 Physicians' assistant 0 0.00 0 29.00

30.00 Adjustment for occupational



A-8-3 0 OCCUPATIONAL THERAPY 67.00 30.00

30.99 Hospice (non-distinct) (see

instructions)

0 ADULTS & PEDIATRICS 30.00 30.99

31.00 Adjustment for speech

pathology costs in excess of


A-8-3 0 SPEECH PATHOLOGY 68.00 31.00

32.00 CAH HIT Adjustment for

Depreciation and Interest

0 0.00 0 32.00

33.00 MO DISCOUNT ON PAYROLL B -23,635 EMPLOYEE BENEFITS DEPARTMENT 4.00 0 33.00

34.00 PROVIDER BASED PHYSICIAN

ADJUST

A -223,768 HOSPICE 116.00 0 34.00

35.00 MISC OTHER REVENUE B -6,518 OTHER ADMINISTRATIVE &

GENERAL

5.06 0 35.00

36.00 GARNISHMENT FEES/BADGES B -143 OTHER ADMINISTRATIVE &

GENERAL

5.06 0 36.00

37.00 CREDIT CARD REBATE B -176,922 OTHER ADMINISTRATIVE &

GENERAL

5.06 0 37.00

38.00 OTHER UNALLOWABLE PHYSICIAN -

LOAN F

A -410,777 OTHER ADMINISTRATIVE &

GENERAL

5.06 0 38.00

39.00 AHA DUES USED FOR LOBBYING A -35,616 OTHER ADMINISTRATIVE &

GENERAL

5.06 0 39.00

40.00 MISC INCOME - PURCHASING B 9,232 PURCHASING RECEIVING AND

STORES

5.03 0 40.00


MCRIF32 - 8.8.159.0 39 | Page


Date/Time Prepared:

Worksheet A-8

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015





(2)


Ref.

1.00 2.00 3.00 4.00 5.00

41.00 MISC INCOME - OTHER A&G B -216 OTHER ADMINISTRATIVE &

GENERAL

5.06 0 41.00

42.00 MISC INCOME - HOUSEKEEPING B -81,074 HOUSEKEEPING 9.00 0 42.00

43.00 MISC INCOME - DIETARY B -300 DIETARY 10.00 0 43.00

44.00 MISC INCOME - ADULTS & PEDS B -910 ADULTS & PEDIATRICS 30.00 0 44.00

45.00 MISC INCOME - NURSERY B -6,000 NURSERY 43.00 0 45.00

45.01 MISC INCOME - OR B -69,996 OPERATING ROOM 50.00 0 45.01

45.02 MISC INCOME - RADIOLOGY B -3,366 RADIOLOGY-DIAGNOSTIC 54.00 0 45.02

45.03 MISC INCOME - CARDIO LAB B -3,470 CARDIOVASCULAR LAB 54.03 0 45.03

45.04 MISC INCOME - THERAPEUTIC

RADIOLOGY

B -54,379 RADIOLOGY-THERAPEUTIC 55.00 0 45.04

45.05 MISC INCOME - NUCLEAR MEDICINE B -1,000 NUCLEAR MEDICINE 56.01 0 45.05

45.06 MISC INCOME - LABORATORY B -87 LABORATORY 60.00 0 45.06

45.07 MISC INCOME - RESPIRATORY

THERAPY

B -2 RESPIRATORY THERAPY 65.00 0 45.07

46.00 MISC INCOME - MED SUPPLIES B -119 MEDICAL SUPPLIES CHARGED TO

PATIENT

71.00 0 46.00

47.00 MISC INCOME - CARDIAC REHAB B -134,440 CARDIAC REHABILITATION 76.97 0 47.00

48.00 0 0.00 0 48.00

49.00 0 0.00 0 49.00

49.01 MISC INCOME - HOME HEALTH B -1,164 HOME HEALTH AGENCY 101.00 0 49.01

49.02 MISC INCOME - HOSPICE B -32 HOSPICE 116.00 0 49.02

49.03 SCHOOL OF RAD TECH TUITION A -205,690 SCHOOL OF RADIOLOGICAL

TECHNOLO

20.03 0 49.03

49.04 SCHOOL OF SURG TECH TUITION A -70,045 SCHOOL OF SURGICAL

TECHNOLOGY

20.02 0 49.04

49.05 SCHOOL OF MED TECH TUITION B -155,520 SCHOOL OF MEDICAL TECHNOLOGY 20.01 0 49.05

49.06 340B DRUG PROGRAM B -625,944 DRUGS CHARGED TO PATIENTS 73.00 0 49.06

49.07 PRISONER MEALS B -45,327 DIETARY 10.00 0 49.07

49.08 INTEREST B -85,155 NEW CAP-REL CSTS-BLDGS & FIX

#9

1.08 11 49.08

49.09 RENTAL INCOME B -738,654 OPERATION OF PLANT 7.00 0 49.09

49.10 HOSPITALIST EXPENSE - SALARY A -31,412 ADULTS & PEDIATRICS 30.00 0 49.10

49.11 HOSPITALIST EXPENSE - OTHER A -269,026 ADULTS & PEDIATRICS 30.00 0 49.11

49.12 ANESTHESIA - PROF - SALARY A -61,667 ANESTHESIOLOGY 53.00 0 49.12

49.13 ANESTHESIA - PROF - OTHER A -387,090 ANESTHESIOLOGY 53.00 0 49.13

49.14 SELF-INSURED COST A -3,404,395 EMPLOYEE BENEFITS DEPARTMENT 4.00 0 49.14

49.15 MHA EXPENSE A -234,381 OTHER ADMINISTRATIVE &

GENERAL

5.06 0 49.15

49.16 MHA PAID TO PPOOL A -565,587 OTHER ADMINISTRATIVE &

GENERAL

5.06 0 49.16

49.17 REAL ESTATE TAXES A -4,137 PURCHASING RECEIVING AND

STORES

5.03 0 49.17

49.18 REAL ESTATE TAXES A -305,239 OPERATION OF PLANT 7.00 0 49.18

49.19 CORPORATE SPONSORSHIP A -268 EMERGENCY 91.00 0 49.19

49.20 NONPATIENT LAB B -432,156 LABORATORY 60.00 0 49.20

49.21 0 0.00 0 49.21

49.22 0 0.00 0 49.22

50.00 TOTAL (sum of lines 1 thru 49)

(Transfer to Worksheet A,

column 6, line 200.)

-44,450,981 50.00

(1) Description - all chapter references in this column pertain to CMS Pub. 15-1.

(2) Basis for adjustment (see instructions).

A. Costs - if cost, including applicable overhead, can be determined.

B. Amount Received - if cost cannot be determined.

(3) Additional adjustments may be made on lines 33 thru 49 and subscripts thereof.

Note: See instructions for column 5 referencing to Worksheet A-7.


MCRIF32 - 8.8.159.0 40 | Page


Date/Time Prepared:

Worksheet A-8-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS AND HOME

OFFICE COSTS

Line No. Cost Center Expense Items Amount of

Allowable Cost

Amount

Included in

Wks. A, column

5

1.00 2.00 3.00 4.00 5.00

A. COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS OR CLAIMED HOME

OFFICE COSTS:

1.00 1.00 CAP REL COSTS-BLDG & FIXT DEPRECIATION 442,269 462,498 1.00

2.00 2.00 CAP REL COSTS-MVBLE EQUIP DEPRECIATION 7,628,258 7,977,175 2.00

3.00 4.00 EMPLOYEE BENEFITS DEPARTMENT BENEFITS 1,462,138 1,605,957 3.00

4.00 4.00 EMPLOYEE BENEFITS DEPARTMENT BENEFITS 1,373,246 1,886,979 4.00

4.01 5.01 COMMUNICATIONS COMMUNICATIONS 591,468 812,736 4.01

4.02 5.02 DATA PROCESSING DATA PROCESSING 4,989,129 6,855,566 4.02

4.03 0.00 0 0 4.03

4.04 5.05 CASHIERING/ACCOUNTS RECEIVAB CREDIT & COLLECTIONS 2,585,852 3,553,221 4.04

4.05 5.06 OTHER ADMINISTRATIVE & GENER OTHER ADMINISTRATIVE & GENER 15,898,358 21,845,945 4.05

4.06 6.00 MAINTENANCE & REPAIRS MAINTENANCE & REPAIRS 547,697 752,591 4.06

4.07 0.00 0 0 4.07

4.08 13.00 NURSING ADMINISTRATION NURSING ADMINISTRATION 616,333 846,903 4.08

4.09 41.00 SUBPROVIDER - IRF SUBPROVIDER - IRF 915 1,257 4.09

4.10 88.01 RURAL HEALTH CLINIC II RURAL HEALTH CLINIC II 21,854 30,030 4.10

4.11 88.02 RURAL HEALTH CLINIC III RURAL HEALTH CLINIC III 14,766 20,290 4.11

4.12 90.01 HYPERBARIC WOUND CLINIC HYPERBARIC WOUND CLINIC 3,126 4,296 4.12

4.13 91.00 EMERGENCY EMERGENCY 16,470 22,632 4.13

4.14 113.00 INTEREST EXPENSE INTEREST EXPENSE 109,466 150,417 4.14

4.15 193.06 SE HOSP PHYSICIANS LLC SE HOSP PHYSICIANS LLC 1,705,529 2,343,569 4.15

4.16 193.11 MARKETING MARKETING 2,880,500 3,958,099 4.16

4.17 0.00 0 0 4.17

4.18 0.00 0 0 4.18

4.19 0.00 0 0 4.19

4.20 0.00 0 0 4.20

4.21 0.00 0 0 4.21

5.00 TOTALS (sum of lines 1-4).

Transfer column 6, line 5 to

Worksheet A-8, column 2,

line 12.

40,887,374 53,130,161 5.00

* The amounts on lines 1-4 (and subscripts as appropriate) are transferred in detail to Worksheet A, column 6, lines as

appropriate.Positive amounts increase cost and negative amounts decrease cost.For related organization or home office cost which

has not been posted to Worksheet A, columns 1 and/or 2, the amount allowable should be indicated in column 4 of this part.

Related Organization(s) and/or Home Office

Symbol (1) Name Percentage of

Ownership

Name Percentage of

Ownership

1.00 2.00 3.00 4.00 5.00

B. INTERRELATIONSHIP TO RELATED ORGANIZATION(S) AND/OR HOME OFFICE:

The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires that you furnish

the information requested under Part B of this worksheet.

This information is used by the Centers for Medicare and Medicaid Services and its intermediaries/contractors in determining that

the costs applicable to services, facilities, and supplies furnished by organizations related to you by common ownership or

control represent reasonable costs as determined under section 1861 of the Social Security Act. If you do not provide all or any

part of the request information, the cost report is considered incomplete and not acceptable for purposes of claiming

reimbursement under title XVIII.

6.00 C 0.00 SE HLTH RIPLEY 100.00 6.00

7.00 C 0.00 SE HLTHSTODDARD 100.00 7.00

8.00 C 0.00 SE HLTHREYNOLDS 100.00 8.00

9.00 C 0.00 SOUTHEAST HOSPI 100.00 9.00

10.00 0.00 0.00 10.00

100.00 G. Other (financial or

non-financial) specify:

100.00

(1) Use the following symbols to indicate interrelationship to related organizations:

A. Individual has financial interest (stockholder, partner, etc.) in both related organization and in provider.

B. Corporation, partnership, or other organization has financial interest in provider.

C. Provider has financial interest in corporation, partnership, or other organization.

D. Director, officer, administrator, or key person of provider or relative of such person has financial interest in related

organization.

E. Individual is director, officer, administrator, or key person of provider and related organization.

F. Director, officer, administrator, or key person of related organization or relative of such person has financial interest in

provider.


MCRIF32 - 8.8.159.0 41 | Page


Date/Time Prepared:

Worksheet A-8-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS AND HOME

OFFICE COSTS

Net

Adjustments

(col. 4 minus

col. 5)*

Wkst. A-7 Ref.

6.00 7.00

A. COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS OR CLAIMED HOME

OFFICE COSTS:

1.00 -20,229 9 1.00

2.00 -348,917 9 2.00

3.00 -143,819 0 3.00

4.00 -513,733 0 4.00

4.01 -221,268 0 4.01

4.02 -1,866,437 0 4.02

4.03 0 0 4.03

4.04 -967,369 0 4.04

4.05 -5,947,587 0 4.05

4.06 -204,894 0 4.06

4.07 0 0 4.07

4.08 -230,570 0 4.08

4.09 -342 0 4.09

4.10 -8,176 0 4.10

4.11 -5,524 0 4.11

4.12 -1,170 0 4.12

4.13 -6,162 0 4.13

4.14 -40,951 0 4.14

4.15 -638,040 0 4.15

4.16 -1,077,599 0 4.16

4.17 0 0 4.17

4.18 0 0 4.18

4.19 0 0 4.19

4.20 0 0 4.20

4.21 0 0 4.21

5.00 -12,242,787 5.00

* The amounts on lines 1-4 (and subscripts as appropriate) are transferred in detail to Worksheet A, column 6, lines as

appropriate.Positive amounts increase cost and negative amounts decrease cost.For related organization or home office cost which

has not been posted to Worksheet A, columns 1 and/or 2, the amount allowable should be indicated in column 4 of this part.

Related Organization(s)

and/or Home Office

Type of Business

6.00

B. INTERRELATIONSHIP TO RELATED ORGANIZATION(S) AND/OR HOME OFFICE:

The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires that you furnish

the information requested under Part B of this worksheet.

This information is used by the Centers for Medicare and Medicaid Services and its intermediaries/contractors in determining that

the costs applicable to services, facilities, and supplies furnished by organizations related to you by common ownership or

control represent reasonable costs as determined under section 1861 of the Social Security Act. If you do not provide all or any

part of the request information, the cost report is considered incomplete and not acceptable for purposes of claiming

reimbursement under title XVIII.

6.00 HOSPITAL 6.00

7.00 HOSPITAL 7.00

8.00 HOSPITAL 8.00

9.00 HOME OFFICE 9.00

10.00 10.00

100.00 100.00

(1) Use the following symbols to indicate interrelationship to related organizations:

A. Individual has financial interest (stockholder, partner, etc.) in both related organization and in provider.

B. Corporation, partnership, or other organization has financial interest in provider.

C. Provider has financial interest in corporation, partnership, or other organization.

D. Director, officer, administrator, or key person of provider or relative of such person has financial interest in related

organization.

E. Individual is director, officer, administrator, or key person of provider and related organization.

F. Director, officer, administrator, or key person of related organization or relative of such person has financial interest in

provider.


MCRIF32 - 8.8.159.0 42 | Page


Date/Time Prepared:

Worksheet A-8-2

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110PROVIDER BASED PHYSICIAN ADJUSTMENT

Wkst. A Line # Cost Center/Physician

Identifier

Total

Remuneration

Professional

Component

Provider

Component

RCE Amount Physician/Prov

ider Component

Hours

1.00 2.00 3.00 4.00 5.00 6.00 7.00

1.00 5.04 ADMITTING 89,182 89,182 0 0 0 1.00

2.00 5.06 OTHER ADMINISTRATIVE &

GENERAL

5,786 5,786 0 0 0 2.00

3.00 30.00 ADULTS & PEDIATRICS 5,346,723 5,346,723 0 0 0 3.00

4.00 40.00 SUBPROVIDER - IPF 633,925 633,925 0 0 0 4.00

5.00 41.00 SUBPROVIDER - IRF 80,828 80,828 0 0 0 5.00

6.00 53.00 ANESTHESIOLOGY 6,862,098 6,862,098 0 0 0 6.00

7.00 54.03 CARDIOVASCULAR LAB 111,193 111,193 0 0 0 7.00

8.00 69.01 CV DIAGNOSTIC 4,422 4,422 0 0 0 8.00

9.00 70.01 NEUROPHYSIOLOGY 84,445 84,445 0 0 0 9.00

10.00 90.01 HYPERBARIC WOUND CLINIC 586,797 586,797 0 0 0 10.00

11.00 91.00 EMERGENCY 6,612,525 6,612,525 0 0 0 11.00

200.00 20,417,924 20,417,924 0 0 200.00


Identifier

Unadjusted RCE

Limit

5 Percent of

Unadjusted RCE

Limit

Cost of

Memberships &

Continuing

Education

Provider

Component

Share of col.

12

Physician Cost

of Malpractice

Insurance

1.00 2.00 8.00 9.00 12.00 13.00 14.00

1.00 5.04 ADMITTING 0 0 0 0 0 1.00


GENERAL

0 0 0 0 0 2.00

3.00 30.00 ADULTS & PEDIATRICS 0 0 0 0 131,225 3.00

4.00 40.00 SUBPROVIDER - IPF 0 0 0 0 11,496 4.00

5.00 41.00 SUBPROVIDER - IRF 0 0 0 0 0 5.00

6.00 53.00 ANESTHESIOLOGY 0 0 0 0 242,894 6.00

7.00 54.03 CARDIOVASCULAR LAB 0 0 0 0 517 7.00

8.00 69.01 CV DIAGNOSTIC 0 0 0 0 0 8.00

9.00 70.01 NEUROPHYSIOLOGY 0 0 0 0 0 9.00

10.00 90.01 HYPERBARIC WOUND CLINIC 0 0 0 0 12,165 10.00

11.00 91.00 EMERGENCY 0 0 0 0 298,790 11.00

200.00 0 0 0 0 697,087 200.00


Identifier

Provider

Component

Share of col.

14

Adjusted RCE

Limit

RCE

Disallowance

Adjustment

1.00 2.00 15.00 16.00 17.00 18.00

1.00 5.04 ADMITTING 0 0 0 89,182 1.00


GENERAL

0 0 0 5,786 2.00

3.00 30.00 ADULTS & PEDIATRICS 0 0 0 5,346,723 3.00

4.00 40.00 SUBPROVIDER - IPF 0 0 0 633,925 4.00

5.00 41.00 SUBPROVIDER - IRF 0 0 0 80,828 5.00

6.00 53.00 ANESTHESIOLOGY 0 0 0 6,862,098 6.00

7.00 54.03 CARDIOVASCULAR LAB 0 0 0 111,193 7.00

8.00 69.01 CV DIAGNOSTIC 0 0 0 4,422 8.00

9.00 70.01 NEUROPHYSIOLOGY 0 0 0 84,445 9.00

10.00 90.01 HYPERBARIC WOUND CLINIC 0 0 0 586,797 10.00

11.00 91.00 EMERGENCY 0 0 0 6,612,525 11.00

200.00 0 0 0 20,417,924 200.00


MCRIF32 - 8.8.159.0 43 | Page


Date/Time Prepared:

Worksheet B

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110COST ALLOCATION - GENERAL SERVICE COSTS

CAPITAL RELATED COSTS

Cost Center Description Net Expenses

for Cost

Allocation

(from Wkst A

col. 7)

BLDG & FIXT NEW CAP-REL

CSTS-BLDGS &

FIX #2

NEW CAP-REL

CSTS-BLDGS &

FIX #3

NEW CAP-REL

CSTS-BLDGS &

FIX #4

0 1.00 1.01 1.02 1.03


1.00 00100 CAP REL COSTS-BLDG & FIXT 277,399 277,399 1.00

1.01 00101 NEW CAP-REL CSTS-BLDGS & FIX #2 304,510 0 304,510 1.01

1.02 00102 NEW CAP-REL CSTS-BLDGS & FIX #3 603,866 0 0 603,866 1.02

1.03 00103 NEW CAP-REL CSTS-BLDGS & FIX #4 336,528 0 0 0 336,528 1.03

1.04 00104 NEW CAP-REL CSTS-BLDGS & FIX #5 0 0 0 0 0 1.04

1.05 00105 NEW CAP-REL CSTS-BLDGS & FIX #6 217,366 0 0 0 0 1.05



1.08 00108 NEW CAP-REL CSTS-BLDGS & FIX #9 11,287,789 0 0 0 0 1.08



2.00 00200 CAP REL COSTS-MVBLE EQUIP 15,957,953 2.00

4.00 00400 EMPLOYEE BENEFITS DEPARTMENT 6,719,611 0 0 0 0 4.00

5.01 01160 COMMUNICATIONS 540,398 2,972 0 0 0 5.01

5.02 00550 DATA PROCESSING 4,913,853 0 4,106 2,047 0 5.02

5.03 00560 PURCHASING RECEIVING AND STORES 1,744,369 0 6,676 59,798 0 5.03

5.04 00570 ADMITTING 2,476,012 0 21,524 0 18,760 5.04

5.05 00580 CASHIERING/ACCOUNTS RECEIVABLE 3,980,715 9,598 0 0 7,584 5.05

5.06 00590 OTHER ADMINISTRATIVE & GENERAL 32,514,502 42,229 20,300 0 52,981 5.06

6.00 00600 MAINTENANCE & REPAIRS 3,419,428 0 0 15,661 39,745 6.00

7.00 00700 OPERATION OF PLANT 4,738,739 17,709 12,962 48,853 14,807 7.00

8.00 00800 LAUNDRY & LINEN SERVICE 30,520 0 1,830 4,449 1,203 8.00

9.00 00900 HOUSEKEEPING 3,392,440 0 9,513 7,979 2,631 9.00

10.00 01000 DIETARY 2,718,549 0 21,285 0 68,713 10.00

11.00 01100 CAFETERIA 0 0 0 0 0 11.00


13.00 01300 NURSING ADMINISTRATION 3,964,927 34,288 16,133 7,163 0 13.00

14.00 01400 CENTRAL SERVICES & SUPPLY 1,722,061 0 1,113 0 0 14.00

15.00 01500 PHARMACY 0 0 0 0 0 15.00


17.00 01700 SOCIAL SERVICE 0 0 0 0 0 17.00


20.00 02000 NURSING SCHOOL 0 0 0 0 0 20.00

20.01 02001 SCHOOL OF MEDICAL TECHNOLOGY 14,937 0 0 0 0 20.01

20.02 02002 SCHOOL OF SURGICAL TECHNOLOGY 0 0 0 0 0 20.02

20.03 02003 SCHOOL OF RADIOLOGICAL TECHNOLO 0 0 0 0 0 20.03





30.00 03000 ADULTS & PEDIATRICS 12,733,565 36,471 71,054 377,118 90,757 30.00

33.01 03301 ADULT SPECIAL CARE 2,151,447 0 0 0 0 33.01

34.01 03401 CARDIOTHORACIC ICU 1,458,446 0 0 0 0 34.01

40.00 04000 SUBPROVIDER - IPF 1,024,740 0 0 77,773 0 40.00

41.00 04100 SUBPROVIDER - IRF 980,506 0 44,623 0 0 41.00

43.00 04300 NURSERY 697,900 0 0 0 10,628 43.00


50.00 05000 OPERATING ROOM 7,782,184 0 0 0 0 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 1,378,992 0 19,494 0 19,820 52.00

53.00 05300 ANESTHESIOLOGY 391,300 0 5,697 0 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 3,250,457 0 0 0 0 54.00

54.01 05401 ULTRASOUND 633,115 0 0 0 0 54.01

54.03 05403 CARDIOVASCULAR LAB 3,375,367 0 0 0 0 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 1,959,112 0 0 0 0 55.00

55.01 05501 CHEMOTHERAPY 795,101 0 0 0 0 55.01

56.01 05601 NUCLEAR MEDICINE 1,442,710 0 0 0 0 56.01

57.00 05700 CT SCAN 987,343 0 0 0 0 57.00

58.00 05800 MRI 581,311 0 0 0 0 58.00

60.00 06000 LABORATORY 8,665,134 0 0 0 0 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 899,221 0 0 0 0 63.00

65.00 06500 RESPIRATORY THERAPY 2,350,111 17,554 0 0 0 65.00

66.00 06600 PHYSICAL THERAPY 926,618 0 0 0 0 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 2,027,386 0 0 0 0 66.01

66.02 06602 PHYSIATRY 0 0 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 235,165 0 0 0 0 67.00

68.00 06800 SPEECH PATHOLOGY 174,478 0 0 0 0 68.00

69.01 06901 CV DIAGNOSTIC 1,414,218 0 0 0 0 69.01


MCRIF32 - 8.8.159.0 44 | Page


Date/Time Prepared:

Worksheet B

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



Cost Center Description Net Expenses

for Cost

Allocation

(from Wkst A

col. 7)


CSTS-BLDGS &

FIX #2

NEW CAP-REL

CSTS-BLDGS &

FIX #3

NEW CAP-REL

CSTS-BLDGS &

FIX #4

0 1.00 1.01 1.02 1.03


70.01 07001 NEUROPHYSIOLOGY 648,398 52,802 0 0 0 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 11,043,821 0 0 0 0 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 16,846,024 0 0 0 0 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 18,813,658 63,776 0 0 0 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 312,458 0 0 0 0 76.97


76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99



88.01 08801 RURAL HEALTH CLINIC II 2,613,658 0 0 0 0 88.01

88.02 08802 RURAL HEALTH CLINIC III 2,237,136 0 0 0 0 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 534,078 0 0 0 0 90.01

90.02 09002 DIABETES CENTER 188,671 0 0 0 0 90.02

91.00 09100 EMERGENCY 4,883,383 0 0 0 0 91.00

91.01 09101 G.I. LABORATORY 898,579 0 46,053 0 0 91.01



101.00 10100 HOME HEALTH AGENCY 1,333,398 0 0 0 0 101.00


113.00 11300 INTEREST EXPENSE 113.00

116.00 11600 HOSPICE 1,813,911 0 0 0 0 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 223,702,599 277,399 302,363 600,841 327,629 118.00


190.00 19000 GIFT, FLOWER, COFFEE SHOP & CANTEEN 0 0 0 3,025 0 190.00

191.01 19101 RESPITE CARE 0 0 0 0 0 191.01



193.03 19303 LACEYS RESTAURANT 11,802 0 0 0 0 193.03

193.04 19304 COMMUNITY WELLNESS 180,177 0 0 0 0 193.04

193.05 19305 HOME INFUSION 0 0 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 30,123,355 0 2,147 0 8,899 193.06

193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 5,279,568 0 0 0 0 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 2,716,690 0 0 0 0 193.11

193.13 19313 HEALTHPOINT 1,776,974 0 0 0 0 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14

194.00 07950 JAZZMANS RESTAURANT 44,953 0 0 0 0 194.00


200.00 Cross Foot Adjustments 200.00

201.00 Negative Cost Centers 0 0 0 0 201.00

202.00 TOTAL (sum lines 118-201) 263,836,731 277,399 304,510 603,866 336,528 202.00


MCRIF32 - 8.8.159.0 45 | Page


Date/Time Prepared:

Worksheet B

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



Cost Center Description NEW CAP-REL

CSTS-BLDGS &

FIX #5

NEW CAP-REL

CSTS-BLDGS &

FIX #6

NEW CAP-REL

CSTS-BLDGS &

FIX #7

NEW CAP-REL

CSTS-BLDGS &

FIX #8

NEW CAP-REL

CSTS-BLDGS &

FIX #9

1.04 1.05 1.06 1.07 1.08


1.00 00100 CAP REL COSTS-BLDG & FIXT 1.00

1.01 00101 NEW CAP-REL CSTS-BLDGS & FIX #2 1.01



1.04 00104 NEW CAP-REL CSTS-BLDGS & FIX #5 0 1.04


1.06 00106 NEW CAP-REL CSTS-BLDGS & FIX #7 0 0 490,924 1.06

1.07 00107 NEW CAP-REL CSTS-BLDGS & FIX #8 0 0 0 852,103 1.07

1.08 00108 NEW CAP-REL CSTS-BLDGS & FIX #9 0 0 0 0 11,287,789 1.08



2.00 00200 CAP REL COSTS-MVBLE EQUIP 2.00

4.00 00400 EMPLOYEE BENEFITS DEPARTMENT 0 64,179 0 0 81,617 4.00

5.01 01160 COMMUNICATIONS 0 0 2,402 0 11,459 5.01

5.02 00550 DATA PROCESSING 0 9,474 7,821 0 53,717 5.02

5.03 00560 PURCHASING RECEIVING AND STORES 0 0 0 0 90,836 5.03

5.04 00570 ADMITTING 0 17,256 0 0 132,452 5.04

5.05 00580 CASHIERING/ACCOUNTS RECEIVABLE 0 0 0 0 31,859 5.05

5.06 00590 OTHER ADMINISTRATIVE & GENERAL 0 11,877 9,043 2,544 285,982 5.06

6.00 00600 MAINTENANCE & REPAIRS 0 0 0 70,994 262,300 6.00

7.00 00700 OPERATION OF PLANT 0 26,539 81,294 0 542,883 7.00

8.00 00800 LAUNDRY & LINEN SERVICE 0 0 328 1,037 65,645 8.00

9.00 00900 HOUSEKEEPING 0 4,642 821 1,863 57,780 9.00

10.00 01000 DIETARY 0 0 0 0 225,146 10.00

11.00 01100 CAFETERIA 0 0 0 0 0 11.00


13.00 01300 NURSING ADMINISTRATION 0 63,331 1,837 0 240,980 13.00

14.00 01400 CENTRAL SERVICES & SUPPLY 0 0 0 0 68,544 14.00

15.00 01500 PHARMACY 0 0 0 0 0 15.00


17.00 01700 SOCIAL SERVICE 0 0 0 0 0 17.00


20.00 02000 NURSING SCHOOL 0 0 0 0 244,591 20.00

20.01 02001 SCHOOL OF MEDICAL TECHNOLOGY 0 0 0 0 17,553 20.01

20.02 02002 SCHOOL OF SURGICAL TECHNOLOGY 0 0 0 0 16,615 20.02

20.03 02003 SCHOOL OF RADIOLOGICAL TECHNOLO 0 0 0 0 38,074 20.03





30.00 03000 ADULTS & PEDIATRICS 0 0 154,982 0 1,438,068 30.00

33.01 03301 ADULT SPECIAL CARE 0 0 54,699 0 185,041 33.01

34.01 03401 CARDIOTHORACIC ICU 0 0 0 146,459 313,899 34.01

40.00 04000 SUBPROVIDER - IPF 0 0 0 0 91,045 40.00

41.00 04100 SUBPROVIDER - IRF 0 0 0 0 139,258 41.00

43.00 04300 NURSERY 0 0 0 0 24,549 43.00


50.00 05000 OPERATING ROOM 0 0 87,052 170,785 725,545 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0 0 0 0 106,601 52.00

53.00 05300 ANESTHESIOLOGY 0 0 0 58,284 142,696 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0 0 0 17,392 247,126 54.00

54.01 05401 ULTRASOUND 0 0 0 12,151 26,043 54.01

54.03 05403 CARDIOVASCULAR LAB 0 0 23,526 45,639 269,037 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0 0 0 173,644 829,160 55.00

55.01 05501 CHEMOTHERAPY 0 0 0 0 371,297 55.01

56.01 05601 NUCLEAR MEDICINE 0 0 0 16,217 34,758 56.01

57.00 05700 CT SCAN 0 0 0 8,943 74,204 57.00

58.00 05800 MRI 0 0 0 0 84,760 58.00

60.00 06000 LABORATORY 0 0 46,605 8,279 251,397 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0 0 1,694 0 5,729 63.00

65.00 06500 RESPIRATORY THERAPY 0 0 0 13,504 48,630 65.00

66.00 06600 PHYSICAL THERAPY 0 0 8,971 0 30,348 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0 0 0 0 267,266 66.01

66.02 06602 PHYSIATRY 0 0 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 0 0 1,848 0 6,250 67.00

68.00 06800 SPEECH PATHOLOGY 0 0 924 0 3,125 68.00

69.01 06901 CV DIAGNOSTIC 0 0 4,516 4,220 24,324 69.01


70.01 07001 NEUROPHYSIOLOGY 0 0 2,561 0 78,527 70.01


MCRIF32 - 8.8.159.0 46 | Page


Date/Time Prepared:

Worksheet B

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015




CSTS-BLDGS &

FIX #5

NEW CAP-REL

CSTS-BLDGS &

FIX #6

NEW CAP-REL

CSTS-BLDGS &

FIX #7

NEW CAP-REL

CSTS-BLDGS &

FIX #8

NEW CAP-REL

CSTS-BLDGS &

FIX #9

1.04 1.05 1.06 1.07 1.08

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 0 0 0 0 0 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0 0 0 0 0 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 0 0 0 1,296 74,308 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 0 20,068 0 0 25,522 76.97


76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99



88.01 08801 RURAL HEALTH CLINIC II 0 0 0 0 295,149 88.01

88.02 08802 RURAL HEALTH CLINIC III 0 0 0 0 196,760 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 0 0 0 0 0 90.01

90.02 09002 DIABETES CENTER 0 0 0 0 86,808 90.02

91.00 09100 EMERGENCY 0 0 0 98,852 211,865 91.00

91.01 09101 G.I. LABORATORY 0 0 0 0 143,720 91.01



101.00 10100 HOME HEALTH AGENCY 0 0 0 0 57,051 101.00



116.00 11600 HOSPICE 0 0 0 0 57,051 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 0 217,366 490,924 852,103 9,434,950 118.00


190.00 19000 GIFT, FLOWER, COFFEE SHOP & CANTEEN 0 0 0 0 39,168 190.00

191.01 19101 RESPITE CARE 0 0 0 0 0 191.01



193.03 19303 LACEYS RESTAURANT 0 0 0 0 67,711 193.03

193.04 19304 COMMUNITY WELLNESS 0 0 0 0 0 193.04

193.05 19305 HOME INFUSION 0 0 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 0 0 0 0 607,260 193.06

193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 0 0 0 0 33,855 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 0 0 0 0 97,486 193.11

193.13 19313 HEALTHPOINT 0 0 0 0 911,662 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14

194.00 07950 JAZZMANS RESTAURANT 0 0 0 0 8,802 194.00

194.01 07951 FOUNDATION OFFICE 0 0 0 0 86,895 194.01


201.00 Negative Cost Centers 0 0 0 0 0 201.00

202.00 TOTAL (sum lines 118-201) 0 217,366 490,924 852,103 11,287,789 202.00


MCRIF32 - 8.8.159.0 47 | Page


Date/Time Prepared:

Worksheet B

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015




CSTS-BLDGS &

FIX #1

NEW CAP-REL

CSTS-BLDGS &

FIX #1

MVBLE EQUIP EMPLOYEE

BENEFITS

DEPARTMENT

COMMUNICATION

S

1.09 1.10 2.00 4.00 5.01














4.00 00400 EMPLOYEE BENEFITS DEPARTMENT 0 0 91,864 6,957,271 4.00

5.01 01160 COMMUNICATIONS 0 0 98,965 0 656,196 5.01

5.02 00550 DATA PROCESSING 0 0 7,611,617 0 10,616 5.02

5.03 00560 PURCHASING RECEIVING AND STORES 0 0 80,483 52,019 5,431 5.03

5.04 00570 ADMITTING 0 0 3,558 142,914 20,244 5.04

5.05 00580 CASHIERING/ACCOUNTS RECEIVABLE 0 0 140,724 52,286 18,269 5.05

5.06 00590 OTHER ADMINISTRATIVE & GENERAL 0 0 259,240 156,801 63,200 5.06

6.00 00600 MAINTENANCE & REPAIRS 0 0 73,941 102,384 7,900 6.00

7.00 00700 OPERATION OF PLANT 0 0 133,253 0 0 7.00

8.00 00800 LAUNDRY & LINEN SERVICE 0 0 0 0 0 8.00

9.00 00900 HOUSEKEEPING 0 0 48,197 151,211 4,691 9.00

10.00 01000 DIETARY 0 0 14,631 90,215 6,172 10.00

11.00 01100 CAFETERIA 0 0 0 0 0 11.00


13.00 01300 NURSING ADMINISTRATION 0 0 97,504 177,186 12,838 13.00

14.00 01400 CENTRAL SERVICES & SUPPLY 0 0 100,873 63,125 3,703 14.00

15.00 01500 PHARMACY 0 0 0 0 0 15.00


17.00 01700 SOCIAL SERVICE 0 0 0 0 0 17.00


20.00 02000 NURSING SCHOOL 0 0 9,791 124,628 10,369 20.00

20.01 02001 SCHOOL OF MEDICAL TECHNOLOGY 0 0 1,121 9,670 0 20.01

20.02 02002 SCHOOL OF SURGICAL TECHNOLOGY 0 0 536 3,776 0 20.02

20.03 02003 SCHOOL OF RADIOLOGICAL TECHNOLO 0 0 573 12,061 0 20.03





30.00 03000 ADULTS & PEDIATRICS 0 0 326,079 820,050 107,886 30.00

33.01 03301 ADULT SPECIAL CARE 0 0 47,274 133,490 9,875 33.01

34.01 03401 CARDIOTHORACIC ICU 0 0 89,874 90,893 6,913 34.01

40.00 04000 SUBPROVIDER - IPF 0 0 7,546 64,461 4,197 40.00

41.00 04100 SUBPROVIDER - IRF 0 0 12,356 64,525 8,147 41.00

43.00 04300 NURSERY 0 0 47,779 47,762 2,469 43.00


50.00 05000 OPERATING ROOM 0 0 1,014,326 345,789 33,081 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0 0 0 82,158 0 52.00

53.00 05300 ANESTHESIOLOGY 0 0 161,200 16,575 6,666 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0 0 614,081 180,404 35,550 54.00

54.01 05401 ULTRASOUND 0 0 89,773 36,962 1,481 54.01


55.00 05500 RADIOLOGY-THERAPEUTIC 0 0 1,048,907 93,959 9,381 55.00

55.01 05501 CHEMOTHERAPY 0 0 36,615 49,206 1,975 55.01

56.01 05601 NUCLEAR MEDICINE 0 0 119,566 24,793 2,963 56.01

57.00 05700 CT SCAN 0 0 878,974 40,959 2,469 57.00

58.00 05800 MRI 0 0 443,400 25,886 4,691 58.00

60.00 06000 LABORATORY 0 0 316,816 283,190 19,009 60.00



65.00 06500 RESPIRATORY THERAPY 0 0 87,421 115,256 5,431 65.00

66.00 06600 PHYSICAL THERAPY 0 0 12,221 62,425 3,209 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0 0 15,473 134,052 19,009 66.01

66.02 06602 PHYSIATRY 0 0 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 0 0 3,190 16,190 0 67.00

68.00 06800 SPEECH PATHOLOGY 0 0 767 11,966 494 68.00

69.01 06901 CV DIAGNOSTIC 0 0 76,893 56,274 11,109 69.01


70.01 07001 NEUROPHYSIOLOGY 0 0 38,521 37,038 7,159 70.01


MCRIF32 - 8.8.159.0 48 | Page


Date/Time Prepared:

Worksheet B

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015




CSTS-BLDGS &

FIX #1

NEW CAP-REL

CSTS-BLDGS &

FIX #1


BENEFITS

DEPARTMENT

COMMUNICATION

S

1.09 1.10 2.00 4.00 5.01



73.00 07300 DRUGS CHARGED TO PATIENTS 0 0 19,660 185,151 5,431 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 0 0 11,457 29,956 3,209 76.97


76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99



88.01 08801 RURAL HEALTH CLINIC II 0 0 20,414 164,138 11,850 88.01

88.02 08802 RURAL HEALTH CLINIC III 0 0 11,963 118,158 3,703 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 0 0 40,096 24,385 5,925 90.01

90.02 09002 DIABETES CENTER 0 0 1,838 12,476 3,209 90.02

91.00 09100 EMERGENCY 0 0 316,316 246,619 19,009 91.00

91.01 09101 G.I. LABORATORY 0 0 138,330 40,480 5,925 91.01



101.00 10100 HOME HEALTH AGENCY 0 0 7,334 81,613 8,147 101.00



116.00 11600 HOSPICE 0 0 321 88,265 9,134 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 0 0 15,352,485 5,066,785 552,014 118.00



191.01 19101 RESPITE CARE 0 0 0 0 0 191.01



193.03 19303 LACEYS RESTAURANT 0 0 3,449 0 2,222 193.03


193.05 19305 HOME INFUSION 0 0 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 0 0 496,331 1,764,802 71,594 193.06

193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 0 0 13,292 40,077 3,456 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 0 0 18,148 10 7,900 193.11

193.13 19313 HEALTHPOINT 0 0 63,207 83,069 16,541 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14

194.00 07950 JAZZMANS RESTAURANT 0 0 10,139 2,364 494 194.00




202.00 TOTAL (sum lines 118-201) 0 0 15,957,953 6,957,271 656,196 202.00


MCRIF32 - 8.8.159.0 49 | Page


Date/Time Prepared:

Worksheet B

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Cost Center Description Subtotal DATA

PROCESSING

PURCHASING

RECEIVING AND

STORES

ADMITTING CASHIERING/AC

COUNTS

RECEIVABLE

5A.01 5.02 5.03 5.04 5.05














4.00 00400 EMPLOYEE BENEFITS DEPARTMENT 4.00

5.01 01160 COMMUNICATIONS 5.01

5.02 00550 DATA PROCESSING 12,613,251 12,613,251 5.02

5.03 00560 PURCHASING RECEIVING AND STORES 2,039,612 117,928 2,157,540 5.03

5.04 00570 ADMITTING 2,832,720 163,785 2,527 2,999,032 5.04

5.05 00580 CASHIERING/ACCOUNTS RECEIVABLE 4,241,035 245,212 2,226 0 4,488,473 5.05

5.06 00590 OTHER ADMINISTRATIVE & GENERAL 33,418,699 1,932,325 8,554 0 0 5.06

6.00 00600 MAINTENANCE & REPAIRS 3,992,353 230,834 442 0 0 6.00

7.00 00700 OPERATION OF PLANT 5,617,039 324,772 61 0 0 7.00

8.00 00800 LAUNDRY & LINEN SERVICE 105,012 6,072 0 0 0 8.00

9.00 00900 HOUSEKEEPING 3,681,768 212,876 570 0 0 9.00

10.00 01000 DIETARY 3,144,711 181,824 236 0 0 10.00

11.00 01100 CAFETERIA 0 0 0 0 0 11.00


13.00 01300 NURSING ADMINISTRATION 4,616,187 266,903 4,761 0 0 13.00

14.00 01400 CENTRAL SERVICES & SUPPLY 1,959,419 113,292 27,488 0 0 14.00

15.00 01500 PHARMACY 0 0 0 0 0 15.00


17.00 01700 SOCIAL SERVICE 0 0 0 0 0 17.00


20.00 02000 NURSING SCHOOL 389,379 22,514 3,705 0 0 20.00

20.01 02001 SCHOOL OF MEDICAL TECHNOLOGY 43,281 2,502 30 0 0 20.01

20.02 02002 SCHOOL OF SURGICAL TECHNOLOGY 20,927 1,210 22 0 0 20.02

20.03 02003 SCHOOL OF RADIOLOGICAL TECHNOLO 50,708 2,932 33 0 0 20.03






33.01 03301 ADULT SPECIAL CARE 2,581,826 149,279 70,401 23,322 34,908 33.01

34.01 03401 CARDIOTHORACIC ICU 2,106,484 121,795 23,232 12,831 19,206 34.01

40.00 04000 SUBPROVIDER - IPF 1,269,762 73,416 648 9,521 14,251 40.00

41.00 04100 SUBPROVIDER - IRF 1,249,415 72,240 2,308 4,983 7,459 41.00

43.00 04300 NURSERY 831,087 48,053 6,646 8,410 12,588 43.00


50.00 05000 OPERATING ROOM 10,158,762 587,369 290,918 320,448 479,648 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 1,607,065 92,919 25,240 20,431 30,582 52.00

53.00 05300 ANESTHESIOLOGY 782,418 45,239 144,123 73,885 110,591 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 4,345,010 251,224 160,916 88,114 131,889 54.00

54.01 05401 ULTRASOUND 799,525 46,228 7,590 33,275 49,806 54.01

54.03 05403 CARDIOVASCULAR LAB 4,351,968 251,626 177,704 110,397 165,243 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 4,114,163 237,877 29,149 57,934 86,716 55.00

55.01 05501 CHEMOTHERAPY 1,254,194 72,516 15,986 14,725 22,041 55.01

56.01 05601 NUCLEAR MEDICINE 1,641,007 94,881 447 69,354 103,809 56.01

57.00 05700 CT SCAN 1,992,892 115,227 30,239 149,073 223,133 57.00

58.00 05800 MRI 1,140,048 65,916 1,127 65,111 97,458 58.00

60.00 06000 LABORATORY 9,590,430 554,509 2,601 271,336 406,137 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 909,958 52,613 1,122 20,795 31,127 63.00

65.00 06500 RESPIRATORY THERAPY 2,637,907 152,521 7,740 68,384 102,358 65.00

66.00 06600 PHYSICAL THERAPY 1,043,792 60,351 409 21,089 31,566 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 2,463,186 142,419 748 41,605 62,274 66.01

66.02 06602 PHYSIATRY 0 0 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 262,643 15,186 33 7,290 10,912 67.00

68.00 06800 SPEECH PATHOLOGY 191,754 11,087 0 5,895 8,823 68.00

69.01 06901 CV DIAGNOSTIC 1,591,554 92,022 2,145 90,965 136,157 69.01


70.01 07001 NEUROPHYSIOLOGY 865,006 50,014 14,155 61,672 92,311 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 11,043,821 638,543 0 314,382 470,569 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 16,846,024 974,020 743,427 276,935 414,517 72.00


MCRIF32 - 8.8.159.0 50 | Page


Date/Time Prepared:

Worksheet B

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



PROCESSING

PURCHASING

RECEIVING AND

STORES


COUNTS

RECEIVABLE

5A.01 5.02 5.03 5.04 5.05

73.00 07300 DRUGS CHARGED TO PATIENTS 19,163,280 1,108,002 1,794 413,997 619,182 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 402,670 23,282 260 2,644 3,958 76.97


76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99



88.01 08801 RURAL HEALTH CLINIC II 3,105,209 179,540 1,429 13,109 19,621 88.01

88.02 08802 RURAL HEALTH CLINIC III 2,567,720 148,463 5,195 12,421 18,592 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 604,484 34,951 1,032 15,237 22,807 90.01

90.02 09002 DIABETES CENTER 293,002 16,941 214 360 539 90.02

91.00 09100 EMERGENCY 5,776,044 333,965 114,889 142,041 212,607 91.00

91.01 09101 G.I. LABORATORY 1,273,087 73,609 47,066 30,699 45,951 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 0 92.00


101.00 10100 HOME HEALTH AGENCY 1,487,543 86,008 2,976 5,136 7,687 101.00



116.00 11600 HOSPICE 1,968,682 113,827 2,479 9,933 14,867 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 219,235,553 11,946,784 2,114,497 2,999,032 4,488,473 118.00


190.00 19000 GIFT, FLOWER, COFFEE SHOP & CANTEEN 43,130 2,494 0 0 0 190.00

191.01 19101 RESPITE CARE 0 0 0 0 0 191.01



193.03 19303 LACEYS RESTAURANT 85,184 4,925 1 0 0 193.03

193.04 19304 COMMUNITY WELLNESS 180,489 10,436 321 0 0 193.04

193.05 19305 HOME INFUSION 0 0 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 33,074,388 0 38,353 0 0 193.06

193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 5,370,248 310,502 615 0 0 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 2,840,234 164,219 1,657 0 0 193.11

193.13 19313 HEALTHPOINT 2,851,453 164,868 1,638 0 0 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14

194.00 07950 JAZZMANS RESTAURANT 66,752 3,860 0 0 0 194.00

194.01 07951 FOUNDATION OFFICE 89,300 5,163 458 0 0 194.01

200.00 Cross Foot Adjustments 0 200.00


202.00 TOTAL (sum lines 118-201) 263,836,731 12,613,251 2,157,540 2,999,032 4,488,473 202.00


MCRIF32 - 8.8.159.0 51 | Page


Date/Time Prepared:

Worksheet B

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Cost Center Description Subtotal OTHER

ADMINISTRATIV

E & GENERAL

MAINTENANCE &

REPAIRS

OPERATION OF

PLANT

LAUNDRY &

LINEN SERVICE

5A.05 5.06 6.00 7.00 8.00
















5.02 00550 DATA PROCESSING 5.02

5.03 00560 PURCHASING RECEIVING AND STORES 5.03

5.04 00570 ADMITTING 5.04

5.05 00580 CASHIERING/ACCOUNTS RECEIVABLE 5.05

5.06 00590 OTHER ADMINISTRATIVE & GENERAL 35,359,578 35,359,578 5.06

6.00 00600 MAINTENANCE & REPAIRS 4,223,629 653,657 4,877,286 6.00

7.00 00700 OPERATION OF PLANT 5,941,872 919,576 971,642 7,833,090 7.00

8.00 00800 LAUNDRY & LINEN SERVICE 111,084 17,192 19,965 52,498 200,739 8.00

9.00 00900 HOUSEKEEPING 3,895,214 602,831 53,241 46,208 42 9.00

10.00 01000 DIETARY 3,326,771 514,858 147,743 180,056 0 10.00

11.00 01100 CAFETERIA 0 0 0 0 0 11.00


13.00 01300 NURSING ADMINISTRATION 4,887,851 756,454 84,298 192,719 0 13.00

14.00 01400 CENTRAL SERVICES & SUPPLY 2,100,199 325,031 59,008 54,817 0 14.00

15.00 01500 PHARMACY 0 0 0 0 0 15.00


17.00 01700 SOCIAL SERVICE 0 0 0 0 0 17.00


20.00 02000 NURSING SCHOOL 415,598 64,319 68,325 195,607 0 20.00

20.01 02001 SCHOOL OF MEDICAL TECHNOLOGY 45,813 7,090 0 14,037 0 20.01

20.02 02002 SCHOOL OF SURGICAL TECHNOLOGY 22,159 3,429 0 13,288 0 20.02

20.03 02003 SCHOOL OF RADIOLOGICAL TECHNOLO 53,673 8,307 0 30,449 0 20.03





30.00 03000 ADULTS & PEDIATRICS 17,495,485 2,707,636 1,026,658 1,150,064 132,269 30.00

33.01 03301 ADULT SPECIAL CARE 2,859,736 442,578 237,808 147,983 9,838 33.01

34.01 03401 CARDIOTHORACIC ICU 2,283,548 353,406 84,741 251,034 7,423 34.01

40.00 04000 SUBPROVIDER - IPF 1,367,598 211,652 84,741 72,811 10,563 40.00

41.00 04100 SUBPROVIDER - IRF 1,336,405 206,825 121,122 111,369 8,732 41.00

43.00 04300 NURSERY 906,784 140,336 12,423 19,633 0 43.00


50.00 05000 OPERATING ROOM 11,837,145 1,831,940 242,689 580,239 17,310 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 1,776,237 274,894 0 85,252 9,253 52.00

53.00 05300 ANESTHESIOLOGY 1,156,256 178,944 20,409 114,118 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 4,977,153 770,274 115,798 197,634 0 54.00

54.01 05401 ULTRASOUND 936,424 144,923 6,655 20,827 0 54.01

54.03 05403 CARDIOVASCULAR LAB 5,056,938 782,622 44,811 215,156 3,718 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 4,525,839 700,428 96,720 663,103 0 55.00

55.01 05501 CHEMOTHERAPY 1,379,462 213,488 17,303 296,937 0 55.01

56.01 05601 NUCLEAR MEDICINE 1,909,498 295,518 3,549 27,797 0 56.01

57.00 05700 CT SCAN 2,510,564 388,540 52,797 59,343 0 57.00

58.00 05800 MRI 1,369,660 211,971 15,972 67,785 0 58.00

60.00 06000 LABORATORY 10,825,013 1,675,301 111,362 201,050 0 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 1,015,615 157,179 3,993 4,582 0 63.00

65.00 06500 RESPIRATORY THERAPY 2,968,910 459,474 23,958 38,891 0 65.00

66.00 06600 PHYSICAL THERAPY 1,157,207 179,092 19,522 24,270 0 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 2,710,232 419,441 0 213,740 0 66.01

66.02 06602 PHYSIATRY 0 0 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 296,064 45,819 13,310 4,998 0 67.00

68.00 06800 SPEECH PATHOLOGY 217,559 33,670 0 2,499 0 68.00

69.01 06901 CV DIAGNOSTIC 1,912,843 296,035 11,979 19,452 0 69.01


70.01 07001 NEUROPHYSIOLOGY 1,083,158 167,632 23,958 62,800 0 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 12,467,315 1,929,467 0 0 0 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 19,254,923 2,979,930 0 0 0 72.00


MCRIF32 - 8.8.159.0 52 | Page


Date/Time Prepared:

Worksheet B

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



ADMINISTRATIV

E & GENERAL

MAINTENANCE &

REPAIRS

OPERATION OF

PLANT

LAUNDRY &

LINEN SERVICE

5A.05 5.06 6.00 7.00 8.00

73.00 07300 DRUGS CHARGED TO PATIENTS 21,306,255 3,297,399 19,965 59,426 0 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 432,814 66,983 20,853 20,410 0 76.97


76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99



88.01 08801 RURAL HEALTH CLINIC II 3,318,908 513,641 44,367 236,039 0 88.01

88.02 08802 RURAL HEALTH CLINIC III 2,752,391 425,966 36,825 157,355 0 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 678,511 105,008 31,944 0 0 90.01

90.02 09002 DIABETES CENTER 311,056 48,140 17,747 69,423 0 90.02

91.00 09100 EMERGENCY 6,579,546 1,018,264 240,914 169,434 284 91.00

91.01 09101 G.I. LABORATORY 1,470,412 227,564 52,797 114,937 1,307 91.01



101.00 10100 HOME HEALTH AGENCY 1,589,350 245,971 18,191 45,625 0 101.00



116.00 11600 HOSPICE 2,109,788 326,515 27,064 45,625 0 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 218,526,043 28,347,210 4,307,167 6,351,320 200,739 118.00


190.00 19000 GIFT, FLOWER, COFFEE SHOP & CANTEEN 45,624 7,061 16,860 31,324 0 190.00

191.01 19101 RESPITE CARE 0 0 0 0 0 191.01



193.03 19303 LACEYS RESTAURANT 90,110 13,946 60,783 54,150 0 193.03


193.05 19305 HOME INFUSION 0 0 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 33,112,741 5,124,589 400,636 485,643 0 193.06

193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 5,681,365 879,259 8,430 27,075 0 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 3,006,110 465,232 47,029 77,962 0 193.11

193.13 19313 HEALTHPOINT 3,017,959 467,065 15,972 729,083 0 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14

194.00 07950 JAZZMANS RESTAURANT 70,612 10,928 4,880 7,040 0 194.00

194.01 07951 FOUNDATION OFFICE 94,921 14,690 15,529 69,493 0 194.01



202.00 TOTAL (sum lines 118-201) 263,836,731 35,359,578 4,877,286 7,833,090 200,739 202.00


MCRIF32 - 8.8.159.0 53 | Page


Date/Time Prepared:

Worksheet B

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Cost Center Description HOUSEKEEPING DIETARY CAFETERIA MAINTENANCE

OF PERSONNEL

NURSING

ADMINISTRATIO

N

9.00 10.00 11.00 12.00 13.00


















5.04 00570 ADMITTING 5.04


5.06 00590 OTHER ADMINISTRATIVE & GENERAL 5.06

6.00 00600 MAINTENANCE & REPAIRS 6.00

7.00 00700 OPERATION OF PLANT 7.00

8.00 00800 LAUNDRY & LINEN SERVICE 8.00

9.00 00900 HOUSEKEEPING 4,597,536 9.00

10.00 01000 DIETARY 107,030 4,276,458 10.00

11.00 01100 CAFETERIA 0 2,226,408 2,226,408 11.00

12.00 01200 MAINTENANCE OF PERSONNEL 0 0 0 0 12.00

13.00 01300 NURSING ADMINISTRATION 114,558 0 81,484 0 6,117,364 13.00

14.00 01400 CENTRAL SERVICES & SUPPLY 32,585 0 38,866 0 0 14.00

15.00 01500 PHARMACY 0 0 0 0 0 15.00


17.00 01700 SOCIAL SERVICE 0 0 0 0 0 17.00


20.00 02000 NURSING SCHOOL 116,274 0 45,516 0 0 20.00

20.01 02001 SCHOOL OF MEDICAL TECHNOLOGY 8,344 0 3,360 0 0 20.01

20.02 02002 SCHOOL OF SURGICAL TECHNOLOGY 7,899 0 1,689 0 0 20.02

20.03 02003 SCHOOL OF RADIOLOGICAL TECHNOLO 18,100 0 3,360 0 0 20.03





30.00 03000 ADULTS & PEDIATRICS 683,629 1,598,647 421,767 0 3,848,267 30.00

33.01 03301 ADULT SPECIAL CARE 87,965 69,251 51,223 0 459,952 33.01

34.01 03401 CARDIOTHORACIC ICU 149,222 70,940 38,457 0 352,630 34.01

40.00 04000 SUBPROVIDER - IPF 43,281 170,097 32,359 0 291,303 40.00

41.00 04100 SUBPROVIDER - IRF 66,201 125,292 27,167 0 245,308 41.00

43.00 04300 NURSERY 11,670 0 14,846 0 137,986 43.00


50.00 05000 OPERATING ROOM 344,911 5,281 126,110 0 0 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 50,676 0 33,283 0 0 52.00

53.00 05300 ANESTHESIOLOGY 67,835 0 43,311 0 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 117,479 0 77,145 0 0 54.00

54.01 05401 ULTRASOUND 12,380 0 11,806 0 0 54.01

54.03 05403 CARDIOVASCULAR LAB 127,895 729 36,235 0 0 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 394,167 0 31,008 0 0 55.00

55.01 05501 CHEMOTHERAPY 176,508 0 21,335 0 0 55.01

56.01 05601 NUCLEAR MEDICINE 16,523 1,653 7,645 0 0 56.01

57.00 05700 CT SCAN 35,275 0 14,953 0 0 57.00

58.00 05800 MRI 40,293 0 7,930 0 0 58.00

60.00 06000 LABORATORY 119,510 0 151,908 0 0 60.00



65.00 06500 RESPIRATORY THERAPY 23,118 0 49,605 0 0 65.00

66.00 06600 PHYSICAL THERAPY 14,427 0 21,318 0 0 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 127,053 0 56,148 0 0 66.01

66.02 06602 PHYSIATRY 0 0 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 2,971 0 5,849 0 0 67.00

68.00 06800 SPEECH PATHOLOGY 1,486 0 3,200 0 0 68.00

69.01 06901 CV DIAGNOSTIC 11,563 0 23,131 0 0 69.01


70.01 07001 NEUROPHYSIOLOGY 37,330 213 15,770 0 0 70.01




MCRIF32 - 8.8.159.0 54 | Page


Date/Time Prepared:

Worksheet B

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



OF PERSONNEL

NURSING

ADMINISTRATIO

N

9.00 10.00 11.00 12.00 13.00

73.00 07300 DRUGS CHARGED TO PATIENTS 35,325 0 51,081 0 0 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 12,133 0 10,525 0 91,990 76.97


76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99



88.01 08801 RURAL HEALTH CLINIC II 140,308 0 41,640 0 0 88.01

88.02 08802 RURAL HEALTH CLINIC III 93,536 0 24,980 0 0 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 0 0 12,926 0 0 90.01

90.02 09002 DIABETES CENTER 41,267 0 4,889 0 45,995 90.02

91.00 09100 EMERGENCY 100,717 7,947 134,538 0 0 91.00

91.01 09101 G.I. LABORATORY 68,322 0 14,188 0 0 91.01



101.00 10100 HOME HEALTH AGENCY 27,121 0 0 0 229,976 101.00



116.00 11600 HOSPICE 27,121 0 0 0 275,971 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 3,716,732 4,276,458 1,792,569 0 5,979,378 118.00


190.00 19000 GIFT, FLOWER, COFFEE SHOP & CANTEEN 18,620 0 0 0 0 190.00

191.01 19101 RESPITE CARE 0 0 0 0 0 191.01





193.05 19305 HOME INFUSION 0 0 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 288,680 0 344,745 0 15,332 193.06

193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 16,094 0 11,717 0 0 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 46,343 0 20,375 0 0 193.11

193.13 19313 HEALTHPOINT 433,387 0 54,690 0 122,654 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14

194.00 07950 JAZZMANS RESTAURANT 4,184 0 2,276 0 0 194.00

194.01 07951 FOUNDATION OFFICE 41,308 0 0 0 0 194.01



202.00 TOTAL (sum lines 118-201) 4,597,536 4,276,458 2,226,408 0 6,117,364 202.00


MCRIF32 - 8.8.159.0 55 | Page


Date/Time Prepared:

Worksheet B

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Cost Center Description CENTRAL

SERVICES &

SUPPLY

PHARMACY MEDICAL

RECORDS &

LIBRARY

SOCIAL

SERVICE

NONPHYSICIAN

ANESTHETISTS

14.00 15.00 16.00 17.00 19.00


















5.04 00570 ADMITTING 5.04






9.00 00900 HOUSEKEEPING 9.00

10.00 01000 DIETARY 10.00

11.00 01100 CAFETERIA 11.00

12.00 01200 MAINTENANCE OF PERSONNEL 12.00

13.00 01300 NURSING ADMINISTRATION 13.00

14.00 01400 CENTRAL SERVICES & SUPPLY 2,610,506 14.00

15.00 01500 PHARMACY 0 0 15.00

16.00 01600 MEDICAL RECORDS & LIBRARY 0 0 0 16.00

17.00 01700 SOCIAL SERVICE 0 0 0 0 17.00


20.00 02000 NURSING SCHOOL 0 0 0 0 20.00

20.01 02001 SCHOOL OF MEDICAL TECHNOLOGY 0 0 0 0 20.01

20.02 02002 SCHOOL OF SURGICAL TECHNOLOGY 0 0 0 0 20.02

20.03 02003 SCHOOL OF RADIOLOGICAL TECHNOLO 0 0 0 0 20.03

21.00 02100 I&R SERVICES-SALARY & FRINGES APPRV 0 0 0 0 21.00

22.00 02200 I&R SERVICES-OTHER PRGM COSTS APPRV 0 0 0 0 22.00

23.00 02300 PARAMEDICAL EDUCATION PROGRAM 0 0 0 0 23.00


30.00 03000 ADULTS & PEDIATRICS 57,952 0 0 0 0 30.00

33.01 03301 ADULT SPECIAL CARE 27,867 0 0 0 0 33.01

34.01 03401 CARDIOTHORACIC ICU 10,951 0 0 0 0 34.01

40.00 04000 SUBPROVIDER - IPF 473 0 0 0 0 40.00

41.00 04100 SUBPROVIDER - IRF 1,464 0 0 0 0 41.00

43.00 04300 NURSERY 2,060 0 0 0 0 43.00


50.00 05000 OPERATING ROOM 543,419 0 0 0 0 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 9,020 0 0 0 0 52.00

53.00 05300 ANESTHESIOLOGY 50,284 0 0 0 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 54,146 0 0 0 0 54.00

54.01 05401 ULTRASOUND 3,040 0 0 0 0 54.01

54.03 05403 CARDIOVASCULAR LAB 255,588 0 0 0 0 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 8,784 0 0 0 0 55.00

55.01 05501 CHEMOTHERAPY 6,449 0 0 0 0 55.01

56.01 05601 NUCLEAR MEDICINE 202 0 0 0 0 56.01

57.00 05700 CT SCAN 11,071 0 0 0 0 57.00

58.00 05800 MRI 916 0 0 0 0 58.00

60.00 06000 LABORATORY 187,882 0 0 0 0 60.00



65.00 06500 RESPIRATORY THERAPY 24,701 0 0 0 0 65.00

66.00 06600 PHYSICAL THERAPY 152 0 0 0 0 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 1,090 0 0 0 0 66.01

66.02 06602 PHYSIATRY 0 0 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 126 0 0 0 0 67.00

68.00 06800 SPEECH PATHOLOGY 14 0 0 0 0 68.00

69.01 06901 CV DIAGNOSTIC 1,531 0 0 0 0 69.01


70.01 07001 NEUROPHYSIOLOGY 6,606 0 0 0 0 70.01




MCRIF32 - 8.8.159.0 56 | Page


Date/Time Prepared:

Worksheet B

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



SERVICES &

SUPPLY

PHARMACY MEDICAL

RECORDS &

LIBRARY

SOCIAL

SERVICE

NONPHYSICIAN

ANESTHETISTS

14.00 15.00 16.00 17.00 19.00

73.00 07300 DRUGS CHARGED TO PATIENTS 0 0 0 0 0 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 117 0 0 0 0 76.97


76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99



88.01 08801 RURAL HEALTH CLINIC II 1,310 0 0 0 0 88.01

88.02 08802 RURAL HEALTH CLINIC III 2,861 0 0 0 0 88.02


90.02 09002 DIABETES CENTER 24 0 0 0 0 90.02

91.00 09100 EMERGENCY 41,370 0 0 0 0 91.00

91.01 09101 G.I. LABORATORY 16,558 0 0 0 0 91.01



101.00 10100 HOME HEALTH AGENCY 1,388 0 0 0 0 101.00



116.00 11600 HOSPICE 1,071 0 0 0 0 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 2,594,676 0 0 0 0 118.00



191.01 19101 RESPITE CARE 0 0 0 0 0 191.01



193.03 19303 LACEYS RESTAURANT 0 0 0 0 0 193.03


193.05 19305 HOME INFUSION 0 0 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 15,830 0 0 0 0 193.06

193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 0 0 0 0 0 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 0 0 0 0 0 193.11

193.13 19313 HEALTHPOINT 0 0 0 0 0 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14

194.00 07950 JAZZMANS RESTAURANT 0 0 0 0 0 194.00




202.00 TOTAL (sum lines 118-201) 2,610,506 0 0 0 0 202.00


MCRIF32 - 8.8.159.0 57 | Page


Date/Time Prepared:

Worksheet B

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


INTERNS &

RESIDENTS

Cost Center Description NURSING

SCHOOL

SCHOOL OF

MEDICAL

TECHNOLOGY

SCHOOL OF

SURGICAL

TECHNOLOGY

SCHOOL OF

RADIOLOGICAL

TECHNOLO

SERVICES-SALA

RY & FRINGES

APPRV

20.00 20.01 20.02 20.03 21.00


















5.04 00570 ADMITTING 5.04







10.00 01000 DIETARY 10.00

11.00 01100 CAFETERIA 11.00



14.00 01400 CENTRAL SERVICES & SUPPLY 14.00

15.00 01500 PHARMACY 15.00

16.00 01600 MEDICAL RECORDS & LIBRARY 16.00

17.00 01700 SOCIAL SERVICE 17.00

19.00 01900 NONPHYSICIAN ANESTHETISTS 19.00

20.00 02000 NURSING SCHOOL 905,639 20.00

20.01 02001 SCHOOL OF MEDICAL TECHNOLOGY 78,644 20.01

20.02 02002 SCHOOL OF SURGICAL TECHNOLOGY 48,464 20.02

20.03 02003 SCHOOL OF RADIOLOGICAL TECHNOLO 113,889 20.03

21.00 02100 I&R SERVICES-SALARY & FRINGES APPRV 0 21.00

22.00 02200 I&R SERVICES-OTHER PRGM COSTS APPRV 22.00

23.00 02300 PARAMEDICAL EDUCATION PROGRAM 23.00


30.00 03000 ADULTS & PEDIATRICS 660,621 0 0 0 0 30.00

33.01 03301 ADULT SPECIAL CARE 0 0 0 0 0 33.01


40.00 04000 SUBPROVIDER - IPF 66,664 0 0 0 0 40.00

41.00 04100 SUBPROVIDER - IRF 49,477 0 0 0 0 41.00

43.00 04300 NURSERY 0 0 0 0 0 43.00


50.00 05000 OPERATING ROOM 8,570 0 48,464 0 0 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0 0 0 0 0 52.00

53.00 05300 ANESTHESIOLOGY 0 0 0 0 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0 0 0 113,889 0 54.00

54.01 05401 ULTRASOUND 0 0 0 0 0 54.01


55.00 05500 RADIOLOGY-THERAPEUTIC 0 0 0 0 0 55.00

55.01 05501 CHEMOTHERAPY 0 0 0 0 0 55.01


57.00 05700 CT SCAN 0 0 0 0 0 57.00

58.00 05800 MRI 0 0 0 0 0 58.00

60.00 06000 LABORATORY 0 78,644 0 0 0 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0 0 0 0 0 63.00

65.00 06500 RESPIRATORY THERAPY 0 0 0 0 0 65.00


66.01 06601 SOUTHEAST OUTPATIENT REHAB 0 0 0 0 0 66.01

66.02 06602 PHYSIATRY 0 0 0 0 0 66.02



69.01 06901 CV DIAGNOSTIC 0 0 0 0 0 69.01


70.01 07001 NEUROPHYSIOLOGY 0 0 0 0 0 70.01


MCRIF32 - 8.8.159.0 58 | Page


Date/Time Prepared:

Worksheet B

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


INTERNS &

RESIDENTS


SCHOOL

SCHOOL OF

MEDICAL

TECHNOLOGY

SCHOOL OF

SURGICAL

TECHNOLOGY

SCHOOL OF

RADIOLOGICAL

TECHNOLO

SERVICES-SALA

RY & FRINGES

APPRV

20.00 20.01 20.02 20.03 21.00




76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00



76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99



88.01 08801 RURAL HEALTH CLINIC II 0 0 0 0 0 88.01

88.02 08802 RURAL HEALTH CLINIC III 0 0 0 0 0 88.02


90.02 09002 DIABETES CENTER 0 0 0 0 0 90.02

91.00 09100 EMERGENCY 45,689 0 0 0 0 91.00

91.01 09101 G.I. LABORATORY 0 0 0 0 0 91.01






116.00 11600 HOSPICE 24,999 0 0 0 0 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 905,639 78,644 48,464 113,889 0 118.00



191.01 19101 RESPITE CARE 0 0 0 0 0 191.01





193.05 19305 HOME INFUSION 0 0 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 0 0 0 0 0 193.06

193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 0 0 0 0 0 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 0 0 0 0 0 193.11

193.13 19313 HEALTHPOINT 0 0 0 0 0 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14



200.00 Cross Foot Adjustments 0 0 0 0 0 200.00


202.00 TOTAL (sum lines 118-201) 905,639 78,644 48,464 113,889 0 202.00


MCRIF32 - 8.8.159.0 59 | Page


Date/Time Prepared:

Worksheet B

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


INTERNS &

RESIDENTS

Cost Center Description SERVICES-OTHE

R PRGM COSTS

APPRV

PARAMEDICAL

EDUCATION

PROGRAM

Subtotal Intern &

Residents

Cost & Post

Stepdown

Adjustments

Total

22.00 23.00 24.00 25.00 26.00


















5.04 00570 ADMITTING 5.04







10.00 01000 DIETARY 10.00

11.00 01100 CAFETERIA 11.00




15.00 01500 PHARMACY 15.00




20.00 02000 NURSING SCHOOL 20.00

20.01 02001 SCHOOL OF MEDICAL TECHNOLOGY 20.01

20.02 02002 SCHOOL OF SURGICAL TECHNOLOGY 20.02

20.03 02003 SCHOOL OF RADIOLOGICAL TECHNOLO 20.03

21.00 02100 I&R SERVICES-SALARY & FRINGES APPRV 21.00

22.00 02200 I&R SERVICES-OTHER PRGM COSTS APPRV 0 22.00

23.00 02300 PARAMEDICAL EDUCATION PROGRAM 0 23.00


30.00 03000 ADULTS & PEDIATRICS 0 0 29,782,995 0 29,782,995 30.00

33.01 03301 ADULT SPECIAL CARE 0 0 4,394,201 0 4,394,201 33.01

34.01 03401 CARDIOTHORACIC ICU 0 0 3,631,943 0 3,631,943 34.01

40.00 04000 SUBPROVIDER - IPF 0 0 2,351,542 0 2,351,542 40.00

41.00 04100 SUBPROVIDER - IRF 0 0 2,299,362 0 2,299,362 41.00

43.00 04300 NURSERY 0 0 1,245,738 0 1,245,738 43.00


50.00 05000 OPERATING ROOM 0 0 15,586,078 0 15,586,078 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0 0 2,238,615 0 2,238,615 52.00

53.00 05300 ANESTHESIOLOGY 0 0 1,631,157 0 1,631,157 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0 0 6,423,518 0 6,423,518 54.00

54.01 05401 ULTRASOUND 0 0 1,136,055 0 1,136,055 54.01

54.03 05403 CARDIOVASCULAR LAB 0 0 6,530,084 0 6,530,084 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0 0 6,420,049 0 6,420,049 55.00

55.01 05501 CHEMOTHERAPY 0 0 2,111,482 0 2,111,482 55.01

56.01 05601 NUCLEAR MEDICINE 0 0 2,262,385 0 2,262,385 56.01

57.00 05700 CT SCAN 0 0 3,072,543 0 3,072,543 57.00

58.00 05800 MRI 0 0 1,714,527 0 1,714,527 58.00

60.00 06000 LABORATORY 0 0 13,350,670 0 13,350,670 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0 0 1,193,892 0 1,193,892 63.00

65.00 06500 RESPIRATORY THERAPY 0 0 3,588,657 0 3,588,657 65.00

66.00 06600 PHYSICAL THERAPY 0 0 1,415,988 0 1,415,988 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0 0 3,527,704 0 3,527,704 66.01

66.02 06602 PHYSIATRY 0 0 0 0 0 66.02


68.00 06800 SPEECH PATHOLOGY 0 0 258,428 0 258,428 68.00

69.01 06901 CV DIAGNOSTIC 0 0 2,276,534 0 2,276,534 69.01


MCRIF32 - 8.8.159.0 60 | Page


Date/Time Prepared:

Worksheet B

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


INTERNS &

RESIDENTS


R PRGM COSTS

APPRV

PARAMEDICAL

EDUCATION

PROGRAM

Subtotal Intern &

Residents

Cost & Post

Stepdown

Adjustments

Total

22.00 23.00 24.00 25.00 26.00


70.01 07001 NEUROPHYSIOLOGY 0 0 1,397,467 0 1,397,467 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 0 0 14,396,782 0 14,396,782 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0 0 23,486,633 0 23,486,633 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 0 0 24,769,451 0 24,769,451 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 0 0 655,825 0 655,825 76.97


76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99



88.01 08801 RURAL HEALTH CLINIC II 0 0 4,296,213 0 4,296,213 88.01

88.02 08802 RURAL HEALTH CLINIC III 0 0 3,493,914 0 3,493,914 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 0 0 831,017 0 831,017 90.01

90.02 09002 DIABETES CENTER 0 0 538,541 0 538,541 90.02

91.00 09100 EMERGENCY 0 0 8,338,703 0 8,338,703 91.00

91.01 09101 G.I. LABORATORY 0 0 1,966,085 0 1,966,085 91.01



101.00 10100 HOME HEALTH AGENCY 0 0 2,171,258 0 2,171,258 101.00



116.00 11600 HOSPICE 0 0 2,838,154 0 2,838,154 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 0 0 207,993,327 0 207,993,327 118.00


190.00 19000 GIFT, FLOWER, COFFEE SHOP & CANTEEN 0 0 119,489 0 119,489 190.00

191.01 19101 RESPITE CARE 0 0 0 0 0 191.01



193.03 19303 LACEYS RESTAURANT 0 0 251,177 0 251,177 193.03

193.04 19304 COMMUNITY WELLNESS 0 0 220,880 0 220,880 193.04

193.05 19305 HOME INFUSION 0 0 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 0 0 39,788,196 0 39,788,196 193.06

193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 0 0 6,623,940 0 6,623,940 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 0 0 3,663,051 0 3,663,051 193.11

193.13 19313 HEALTHPOINT 0 0 4,840,810 0 4,840,810 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14

194.00 07950 JAZZMANS RESTAURANT 0 0 99,920 0 99,920 194.00

194.01 07951 FOUNDATION OFFICE 0 0 235,941 0 235,941 194.01

200.00 Cross Foot Adjustments 0 0 0 0 0 200.00


202.00 TOTAL (sum lines 118-201) 0 0 263,836,731 0 263,836,731 202.00


MCRIF32 - 8.8.159.0 61 | Page


Date/Time Prepared:

Worksheet B

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110ALLOCATION OF CAPITAL RELATED COSTS


Cost Center Description Directly

Assigned New

Capital

Related Costs


CSTS-BLDGS &

FIX #2

NEW CAP-REL

CSTS-BLDGS &

FIX #3

NEW CAP-REL

CSTS-BLDGS &

FIX #4

0 1.00 1.01 1.02 1.03














4.00 00400 EMPLOYEE BENEFITS DEPARTMENT 0 0 0 0 0 4.00

5.01 01160 COMMUNICATIONS 29,225 2,972 0 0 0 5.01

5.02 00550 DATA PROCESSING 40 0 4,106 2,047 0 5.02

5.03 00560 PURCHASING RECEIVING AND STORES 38,966 0 6,676 59,798 0 5.03

5.04 00570 ADMITTING 0 0 21,524 0 18,760 5.04

5.05 00580 CASHIERING/ACCOUNTS RECEIVABLE 0 9,598 0 0 7,584 5.05

5.06 00590 OTHER ADMINISTRATIVE & GENERAL 14,650 42,229 20,300 0 52,981 5.06

6.00 00600 MAINTENANCE & REPAIRS 13,970 0 0 15,661 39,745 6.00

7.00 00700 OPERATION OF PLANT 1,493,755 17,709 12,962 48,853 14,807 7.00

8.00 00800 LAUNDRY & LINEN SERVICE 0 0 1,830 4,449 1,203 8.00

9.00 00900 HOUSEKEEPING 0 0 9,513 7,979 2,631 9.00

10.00 01000 DIETARY 960 0 21,285 0 68,713 10.00

11.00 01100 CAFETERIA 0 0 0 0 0 11.00


13.00 01300 NURSING ADMINISTRATION 0 34,288 16,133 7,163 0 13.00

14.00 01400 CENTRAL SERVICES & SUPPLY 284,329 0 1,113 0 0 14.00

15.00 01500 PHARMACY 0 0 0 0 0 15.00


17.00 01700 SOCIAL SERVICE 0 0 0 0 0 17.00


20.00 02000 NURSING SCHOOL 0 0 0 0 0 20.00

20.01 02001 SCHOOL OF MEDICAL TECHNOLOGY 0 0 0 0 0 20.01







30.00 03000 ADULTS & PEDIATRICS 62,740 36,471 71,054 377,118 90,757 30.00

33.01 03301 ADULT SPECIAL CARE 43,214 0 0 0 0 33.01


40.00 04000 SUBPROVIDER - IPF 0 0 0 77,773 0 40.00

41.00 04100 SUBPROVIDER - IRF 4,968 0 44,623 0 0 41.00

43.00 04300 NURSERY 0 0 0 0 10,628 43.00


50.00 05000 OPERATING ROOM 123,313 0 0 0 0 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0 0 19,494 0 19,820 52.00

53.00 05300 ANESTHESIOLOGY 0 0 5,697 0 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 6,600 0 0 0 0 54.00

54.01 05401 ULTRASOUND 0 0 0 0 0 54.01



55.01 05501 CHEMOTHERAPY 0 0 0 0 0 55.01


57.00 05700 CT SCAN 0 0 0 0 0 57.00

58.00 05800 MRI 0 0 0 0 0 58.00

60.00 06000 LABORATORY 26,625 0 0 0 0 60.00



65.00 06500 RESPIRATORY THERAPY 84,579 17,554 0 0 0 65.00



66.02 06602 PHYSIATRY 0 0 0 0 0 66.02



69.01 06901 CV DIAGNOSTIC 0 0 0 0 0 69.01



MCRIF32 - 8.8.159.0 62 | Page


Date/Time Prepared:

Worksheet B

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



Cost Center Description Directly

Assigned New

Capital

Related Costs


CSTS-BLDGS &

FIX #2

NEW CAP-REL

CSTS-BLDGS &

FIX #3

NEW CAP-REL

CSTS-BLDGS &

FIX #4

0 1.00 1.01 1.02 1.03

70.01 07001 NEUROPHYSIOLOGY 1,700 52,802 0 0 0 70.01



73.00 07300 DRUGS CHARGED TO PATIENTS 395,160 63,776 0 0 0 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00



76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99






90.02 09002 DIABETES CENTER 0 0 0 0 0 90.02

91.00 09100 EMERGENCY 98,696 0 0 0 0 91.00

91.01 09101 G.I. LABORATORY 204,689 0 46,053 0 0 91.01






116.00 11600 HOSPICE 30,305 0 0 0 0 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 3,289,042 277,399 302,363 600,841 327,629 118.00



191.01 19101 RESPITE CARE 0 0 0 0 0 191.01





193.05 19305 HOME INFUSION 0 0 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 37,253 0 2,147 0 8,899 193.06

193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 15,350 0 0 0 0 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 10,567 0 0 0 0 193.11

193.13 19313 HEALTHPOINT 0 0 0 0 0 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14





202.00 TOTAL (sum lines 118-201) 3,352,212 277,399 304,510 603,866 336,528 202.00


MCRIF32 - 8.8.159.0 63 | Page


Date/Time Prepared:

Worksheet B

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015




CSTS-BLDGS &

FIX #5

NEW CAP-REL

CSTS-BLDGS &

FIX #6

NEW CAP-REL

CSTS-BLDGS &

FIX #7

NEW CAP-REL

CSTS-BLDGS &

FIX #8

NEW CAP-REL

CSTS-BLDGS &

FIX #9

1.04 1.05 1.06 1.07 1.08














4.00 00400 EMPLOYEE BENEFITS DEPARTMENT 0 64,179 0 0 81,617 4.00

5.01 01160 COMMUNICATIONS 0 0 2,402 0 11,459 5.01

5.02 00550 DATA PROCESSING 0 9,474 7,821 0 53,717 5.02

5.03 00560 PURCHASING RECEIVING AND STORES 0 0 0 0 90,836 5.03

5.04 00570 ADMITTING 0 17,256 0 0 132,452 5.04

5.05 00580 CASHIERING/ACCOUNTS RECEIVABLE 0 0 0 0 31,859 5.05

5.06 00590 OTHER ADMINISTRATIVE & GENERAL 0 11,877 9,043 2,544 285,982 5.06

6.00 00600 MAINTENANCE & REPAIRS 0 0 0 70,994 262,300 6.00

7.00 00700 OPERATION OF PLANT 0 26,539 81,294 0 542,883 7.00

8.00 00800 LAUNDRY & LINEN SERVICE 0 0 328 1,037 65,645 8.00

9.00 00900 HOUSEKEEPING 0 4,642 821 1,863 57,780 9.00

10.00 01000 DIETARY 0 0 0 0 225,146 10.00

11.00 01100 CAFETERIA 0 0 0 0 0 11.00


13.00 01300 NURSING ADMINISTRATION 0 63,331 1,837 0 240,980 13.00

14.00 01400 CENTRAL SERVICES & SUPPLY 0 0 0 0 68,544 14.00

15.00 01500 PHARMACY 0 0 0 0 0 15.00


17.00 01700 SOCIAL SERVICE 0 0 0 0 0 17.00


20.00 02000 NURSING SCHOOL 0 0 0 0 244,591 20.00

20.01 02001 SCHOOL OF MEDICAL TECHNOLOGY 0 0 0 0 17,553 20.01

20.02 02002 SCHOOL OF SURGICAL TECHNOLOGY 0 0 0 0 16,615 20.02

20.03 02003 SCHOOL OF RADIOLOGICAL TECHNOLO 0 0 0 0 38,074 20.03





30.00 03000 ADULTS & PEDIATRICS 0 0 154,982 0 1,438,068 30.00

33.01 03301 ADULT SPECIAL CARE 0 0 54,699 0 185,041 33.01

34.01 03401 CARDIOTHORACIC ICU 0 0 0 146,459 313,899 34.01

40.00 04000 SUBPROVIDER - IPF 0 0 0 0 91,045 40.00

41.00 04100 SUBPROVIDER - IRF 0 0 0 0 139,258 41.00

43.00 04300 NURSERY 0 0 0 0 24,549 43.00


50.00 05000 OPERATING ROOM 0 0 87,052 170,785 725,545 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0 0 0 0 106,601 52.00

53.00 05300 ANESTHESIOLOGY 0 0 0 58,284 142,696 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0 0 0 17,392 247,126 54.00

54.01 05401 ULTRASOUND 0 0 0 12,151 26,043 54.01


55.00 05500 RADIOLOGY-THERAPEUTIC 0 0 0 173,644 829,160 55.00

55.01 05501 CHEMOTHERAPY 0 0 0 0 371,297 55.01

56.01 05601 NUCLEAR MEDICINE 0 0 0 16,217 34,758 56.01

57.00 05700 CT SCAN 0 0 0 8,943 74,204 57.00

58.00 05800 MRI 0 0 0 0 84,760 58.00

60.00 06000 LABORATORY 0 0 46,605 8,279 251,397 60.00



65.00 06500 RESPIRATORY THERAPY 0 0 0 13,504 48,630 65.00

66.00 06600 PHYSICAL THERAPY 0 0 8,971 0 30,348 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0 0 0 0 267,266 66.01

66.02 06602 PHYSIATRY 0 0 0 0 0 66.02


68.00 06800 SPEECH PATHOLOGY 0 0 924 0 3,125 68.00

69.01 06901 CV DIAGNOSTIC 0 0 4,516 4,220 24,324 69.01


70.01 07001 NEUROPHYSIOLOGY 0 0 2,561 0 78,527 70.01


MCRIF32 - 8.8.159.0 64 | Page


Date/Time Prepared:

Worksheet B

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015




CSTS-BLDGS &

FIX #5

NEW CAP-REL

CSTS-BLDGS &

FIX #6

NEW CAP-REL

CSTS-BLDGS &

FIX #7

NEW CAP-REL

CSTS-BLDGS &

FIX #8

NEW CAP-REL

CSTS-BLDGS &

FIX #9

1.04 1.05 1.06 1.07 1.08



73.00 07300 DRUGS CHARGED TO PATIENTS 0 0 0 1,296 74,308 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 0 20,068 0 0 25,522 76.97


76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99



88.01 08801 RURAL HEALTH CLINIC II 0 0 0 0 295,149 88.01

88.02 08802 RURAL HEALTH CLINIC III 0 0 0 0 196,760 88.02


90.02 09002 DIABETES CENTER 0 0 0 0 86,808 90.02

91.00 09100 EMERGENCY 0 0 0 98,852 211,865 91.00

91.01 09101 G.I. LABORATORY 0 0 0 0 143,720 91.01






116.00 11600 HOSPICE 0 0 0 0 57,051 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 0 217,366 490,924 852,103 9,434,950 118.00


190.00 19000 GIFT, FLOWER, COFFEE SHOP & CANTEEN 0 0 0 0 39,168 190.00

191.01 19101 RESPITE CARE 0 0 0 0 0 191.01



193.03 19303 LACEYS RESTAURANT 0 0 0 0 67,711 193.03


193.05 19305 HOME INFUSION 0 0 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 0 0 0 0 607,260 193.06

193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 0 0 0 0 33,855 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 0 0 0 0 97,486 193.11

193.13 19313 HEALTHPOINT 0 0 0 0 911,662 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14

194.00 07950 JAZZMANS RESTAURANT 0 0 0 0 8,802 194.00




202.00 TOTAL (sum lines 118-201) 0 217,366 490,924 852,103 11,287,789 202.00


MCRIF32 - 8.8.159.0 65 | Page


Date/Time Prepared:

Worksheet B

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015




CSTS-BLDGS &

FIX #1

NEW CAP-REL

CSTS-BLDGS &

FIX #1

MVBLE EQUIP Subtotal EMPLOYEE

BENEFITS

DEPARTMENT

1.09 1.10 2.00 2A 4.00














4.00 00400 EMPLOYEE BENEFITS DEPARTMENT 0 0 91,864 237,660 237,660 4.00

5.01 01160 COMMUNICATIONS 0 0 98,965 145,023 0 5.01

5.02 00550 DATA PROCESSING 0 0 7,611,617 7,688,822 0 5.02

5.03 00560 PURCHASING RECEIVING AND STORES 0 0 80,483 276,759 1,777 5.03

5.04 00570 ADMITTING 0 0 3,558 193,550 4,882 5.04

5.05 00580 CASHIERING/ACCOUNTS RECEIVABLE 0 0 140,724 189,765 1,786 5.05

5.06 00590 OTHER ADMINISTRATIVE & GENERAL 0 0 259,240 698,846 5,356 5.06

6.00 00600 MAINTENANCE & REPAIRS 0 0 73,941 476,611 3,497 6.00

7.00 00700 OPERATION OF PLANT 0 0 133,253 2,372,055 0 7.00

8.00 00800 LAUNDRY & LINEN SERVICE 0 0 0 74,492 0 8.00

9.00 00900 HOUSEKEEPING 0 0 48,197 133,426 5,165 9.00

10.00 01000 DIETARY 0 0 14,631 330,735 3,082 10.00

11.00 01100 CAFETERIA 0 0 0 0 0 11.00


13.00 01300 NURSING ADMINISTRATION 0 0 97,504 461,236 6,052 13.00

14.00 01400 CENTRAL SERVICES & SUPPLY 0 0 100,873 454,859 2,156 14.00

15.00 01500 PHARMACY 0 0 0 0 0 15.00


17.00 01700 SOCIAL SERVICE 0 0 0 0 0 17.00


20.00 02000 NURSING SCHOOL 0 0 9,791 254,382 4,257 20.00

20.01 02001 SCHOOL OF MEDICAL TECHNOLOGY 0 0 1,121 18,674 330 20.01

20.02 02002 SCHOOL OF SURGICAL TECHNOLOGY 0 0 536 17,151 129 20.02






30.00 03000 ADULTS & PEDIATRICS 0 0 326,079 2,557,269 28,012 30.00

33.01 03301 ADULT SPECIAL CARE 0 0 47,274 330,228 4,560 33.01

34.01 03401 CARDIOTHORACIC ICU 0 0 89,874 568,266 3,105 34.01

40.00 04000 SUBPROVIDER - IPF 0 0 7,546 176,364 2,202 40.00

41.00 04100 SUBPROVIDER - IRF 0 0 12,356 201,205 2,204 41.00

43.00 04300 NURSERY 0 0 47,779 82,956 1,632 43.00


50.00 05000 OPERATING ROOM 0 0 1,014,326 2,121,021 11,812 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0 0 0 145,915 2,806 52.00

53.00 05300 ANESTHESIOLOGY 0 0 161,200 367,877 566 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0 0 614,081 885,199 6,162 54.00

54.01 05401 ULTRASOUND 0 0 89,773 127,967 1,263 54.01

54.03 05403 CARDIOVASCULAR LAB 0 0 527,058 1,140,781 3,517 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0 0 1,048,907 2,051,711 3,210 55.00

55.01 05501 CHEMOTHERAPY 0 0 36,615 407,912 1,681 55.01

56.01 05601 NUCLEAR MEDICINE 0 0 119,566 170,541 847 56.01

57.00 05700 CT SCAN 0 0 878,974 962,121 1,399 57.00

58.00 05800 MRI 0 0 443,400 528,160 884 58.00

60.00 06000 LABORATORY 0 0 316,816 649,722 9,674 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0 0 1,775 9,198 2 63.00

65.00 06500 RESPIRATORY THERAPY 0 0 87,421 251,688 3,937 65.00

66.00 06600 PHYSICAL THERAPY 0 0 12,221 51,540 2,132 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0 0 15,473 282,739 4,579 66.01

66.02 06602 PHYSIATRY 0 0 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 0 0 3,190 11,288 553 67.00

68.00 06800 SPEECH PATHOLOGY 0 0 767 4,816 409 68.00

69.01 06901 CV DIAGNOSTIC 0 0 76,893 109,953 1,922 69.01


70.01 07001 NEUROPHYSIOLOGY 0 0 38,521 174,111 1,265 70.01


MCRIF32 - 8.8.159.0 66 | Page


Date/Time Prepared:

Worksheet B

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015




CSTS-BLDGS &

FIX #1

NEW CAP-REL

CSTS-BLDGS &

FIX #1

MVBLE EQUIP Subtotal EMPLOYEE

BENEFITS

DEPARTMENT

1.09 1.10 2.00 2A 4.00



73.00 07300 DRUGS CHARGED TO PATIENTS 0 0 19,660 554,200 6,325 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 0 0 11,457 57,047 1,023 76.97


76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99



88.01 08801 RURAL HEALTH CLINIC II 0 0 20,414 315,563 5,607 88.01

88.02 08802 RURAL HEALTH CLINIC III 0 0 11,963 208,723 4,036 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 0 0 40,096 40,096 833 90.01

90.02 09002 DIABETES CENTER 0 0 1,838 88,646 426 90.02

91.00 09100 EMERGENCY 0 0 316,316 725,729 8,424 91.00

91.01 09101 G.I. LABORATORY 0 0 138,330 532,792 1,383 91.01



101.00 10100 HOME HEALTH AGENCY 0 0 7,334 101,388 2,788 101.00



116.00 11600 HOSPICE 0 0 321 87,677 3,015 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 0 0 15,352,485 31,145,102 173,076 118.00



191.01 19101 RESPITE CARE 0 0 0 0 0 191.01



193.03 19303 LACEYS RESTAURANT 0 0 3,449 71,160 0 193.03


193.05 19305 HOME INFUSION 0 0 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 0 0 496,331 1,151,890 60,290 193.06

193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 0 0 13,292 62,497 1,369 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 0 0 18,148 126,201 0 193.11

193.13 19313 HEALTHPOINT 0 0 63,207 974,869 2,838 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14

194.00 07950 JAZZMANS RESTAURANT 0 0 10,139 18,941 81 194.00

194.01 07951 FOUNDATION OFFICE 0 0 311 87,206 0 194.01



202.00 TOTAL (sum lines 118-201) 0 0 15,957,953 33,680,650 237,660 202.00


MCRIF32 - 8.8.159.0 67 | Page


Date/Time Prepared:

Worksheet B

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Cost Center Description COMMUNICATION

S

DATA

PROCESSING

PURCHASING

RECEIVING AND

STORES


COUNTS

RECEIVABLE

5.01 5.02 5.03 5.04 5.05















5.01 01160 COMMUNICATIONS 145,023 5.01

5.02 00550 DATA PROCESSING 2,346 7,691,168 5.02

5.03 00560 PURCHASING RECEIVING AND STORES 1,200 71,909 351,645 5.03

5.04 00570 ADMITTING 4,474 99,870 412 303,188 5.04

5.05 00580 CASHIERING/ACCOUNTS RECEIVABLE 4,038 149,522 363 0 345,474 5.05

5.06 00590 OTHER ADMINISTRATIVE & GENERAL 13,968 1,178,315 1,394 0 0 5.06

6.00 00600 MAINTENANCE & REPAIRS 1,746 140,754 72 0 0 6.00

7.00 00700 OPERATION OF PLANT 0 198,034 10 0 0 7.00

8.00 00800 LAUNDRY & LINEN SERVICE 0 3,702 0 0 0 8.00

9.00 00900 HOUSEKEEPING 1,037 129,804 93 0 0 9.00

10.00 01000 DIETARY 1,364 110,870 39 0 0 10.00

11.00 01100 CAFETERIA 0 0 0 0 0 11.00


13.00 01300 NURSING ADMINISTRATION 2,837 162,748 776 0 0 13.00

14.00 01400 CENTRAL SERVICES & SUPPLY 818 69,081 4,480 0 0 14.00

15.00 01500 PHARMACY 0 0 0 0 0 15.00


17.00 01700 SOCIAL SERVICE 0 0 0 0 0 17.00


20.00 02000 NURSING SCHOOL 2,292 13,728 604 0 0 20.00

20.01 02001 SCHOOL OF MEDICAL TECHNOLOGY 0 1,526 5 0 0 20.01


20.03 02003 SCHOOL OF RADIOLOGICAL TECHNOLO 0 1,788 5 0 0 20.03






33.01 03301 ADULT SPECIAL CARE 2,182 91,025 11,474 2,359 2,689 33.01

34.01 03401 CARDIOTHORACIC ICU 1,528 74,266 3,786 1,298 1,480 34.01

40.00 04000 SUBPROVIDER - IPF 928 44,767 106 963 1,098 40.00

41.00 04100 SUBPROVIDER - IRF 1,801 44,049 376 504 575 41.00

43.00 04300 NURSERY 546 29,301 1,083 851 970 43.00


50.00 05000 OPERATING ROOM 7,311 358,157 47,415 32,410 36,951 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0 56,659 4,114 2,066 2,356 52.00

53.00 05300 ANESTHESIOLOGY 1,473 27,585 23,490 7,473 8,520 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 7,857 153,188 26,227 8,912 10,160 54.00

54.01 05401 ULTRASOUND 327 28,188 1,237 3,365 3,837 54.01

54.03 05403 CARDIOVASCULAR LAB 1,855 153,433 28,963 11,165 12,730 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 2,073 145,049 4,751 5,859 6,680 55.00

55.01 05501 CHEMOTHERAPY 436 44,218 2,605 1,489 1,698 55.01

56.01 05601 NUCLEAR MEDICINE 655 57,855 73 7,014 7,997 56.01

57.00 05700 CT SCAN 546 70,261 4,929 15,077 17,190 57.00

58.00 05800 MRI 1,037 40,194 184 6,585 7,508 58.00

60.00 06000 LABORATORY 4,201 338,120 424 27,443 31,288 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 327 32,081 183 2,103 2,398 63.00

65.00 06500 RESPIRATORY THERAPY 1,200 93,002 1,262 6,916 7,885 65.00

66.00 06600 PHYSICAL THERAPY 709 36,800 67 2,133 2,432 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 4,201 86,842 122 4,208 4,797 66.01

66.02 06602 PHYSIATRY 0 0 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 0 9,260 5 737 841 67.00

68.00 06800 SPEECH PATHOLOGY 109 6,760 0 596 680 68.00

69.01 06901 CV DIAGNOSTIC 2,455 56,112 350 9,200 10,489 69.01


70.01 07001 NEUROPHYSIOLOGY 1,582 30,497 2,307 6,237 7,111 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 0 389,361 0 31,796 36,251 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0 593,923 121,165 28,009 31,933 72.00


MCRIF32 - 8.8.159.0 68 | Page


Date/Time Prepared:

Worksheet B

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Cost Center Description COMMUNICATION

S

DATA

PROCESSING

PURCHASING

RECEIVING AND

STORES


COUNTS

RECEIVABLE

5.01 5.02 5.03 5.04 5.05

73.00 07300 DRUGS CHARGED TO PATIENTS 1,200 675,621 292 41,743 47,393 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 709 14,197 42 267 305 76.97


76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99



88.01 08801 RURAL HEALTH CLINIC II 2,619 109,477 233 1,326 1,512 88.01

88.02 08802 RURAL HEALTH CLINIC III 818 90,528 847 1,256 1,432 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 1,309 21,312 168 1,541 1,757 90.01

90.02 09002 DIABETES CENTER 709 10,330 35 36 42 90.02

91.00 09100 EMERGENCY 4,201 203,640 18,725 14,366 16,379 91.00

91.01 09101 G.I. LABORATORY 1,309 44,884 7,671 3,105 3,540 91.01



101.00 10100 HOME HEALTH AGENCY 1,801 52,445 485 519 592 101.00



116.00 11600 HOSPICE 2,019 69,408 404 1,005 1,145 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 121,998 7,284,781 344,630 303,188 345,474 118.00


190.00 19000 GIFT, FLOWER, COFFEE SHOP & CANTEEN 109 1,521 0 0 0 190.00

191.01 19101 RESPITE CARE 0 0 0 0 0 191.01



193.03 19303 LACEYS RESTAURANT 491 3,003 0 0 0 193.03

193.04 19304 COMMUNITY WELLNESS 0 6,363 52 0 0 193.04

193.05 19305 HOME INFUSION 0 0 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 15,823 0 6,251 0 0 193.06

193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 764 189,333 100 0 0 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 1,746 100,135 270 0 0 193.11

193.13 19313 HEALTHPOINT 3,656 100,531 267 0 0 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14

194.00 07950 JAZZMANS RESTAURANT 109 2,353 0 0 0 194.00

194.01 07951 FOUNDATION OFFICE 327 3,148 75 0 0 194.01



202.00 TOTAL (sum lines 118-201) 145,023 7,691,168 351,645 303,188 345,474 202.00


MCRIF32 - 8.8.159.0 69 | Page


Date/Time Prepared:

Worksheet B

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Cost Center Description OTHER

ADMINISTRATIV

E & GENERAL

MAINTENANCE &

REPAIRS

OPERATION OF

PLANT

LAUNDRY &

LINEN SERVICE

HOUSEKEEPING

5.06 6.00 7.00 8.00 9.00


















5.04 00570 ADMITTING 5.04


5.06 00590 OTHER ADMINISTRATIVE & GENERAL 1,897,879 5.06

6.00 00600 MAINTENANCE & REPAIRS 35,086 657,766 6.00

7.00 00700 OPERATION OF PLANT 49,359 131,039 2,750,497 7.00

8.00 00800 LAUNDRY & LINEN SERVICE 923 2,693 18,434 100,244 8.00

9.00 00900 HOUSEKEEPING 32,358 7,180 16,225 21 325,309 9.00

10.00 01000 DIETARY 27,635 19,925 63,225 0 7,573 10.00

11.00 01100 CAFETERIA 0 0 0 0 0 11.00


13.00 01300 NURSING ADMINISTRATION 40,603 11,369 67,671 0 8,106 13.00

14.00 01400 CENTRAL SERVICES & SUPPLY 17,446 7,958 19,248 0 2,306 14.00

15.00 01500 PHARMACY 0 0 0 0 0 15.00


17.00 01700 SOCIAL SERVICE 0 0 0 0 0 17.00


20.00 02000 NURSING SCHOOL 3,452 9,215 68,685 0 8,227 20.00

20.01 02001 SCHOOL OF MEDICAL TECHNOLOGY 381 0 4,929 0 590 20.01

20.02 02002 SCHOOL OF SURGICAL TECHNOLOGY 184 0 4,666 0 559 20.02

20.03 02003 SCHOOL OF RADIOLOGICAL TECHNOLO 446 0 10,692 0 1,281 20.03






33.01 03301 ADULT SPECIAL CARE 23,756 32,072 51,962 4,913 6,224 33.01

34.01 03401 CARDIOTHORACIC ICU 18,969 11,428 88,148 3,707 10,559 34.01

40.00 04000 SUBPROVIDER - IPF 11,361 11,428 25,567 5,275 3,062 40.00

41.00 04100 SUBPROVIDER - IRF 11,102 16,335 39,106 4,361 4,684 41.00

43.00 04300 NURSERY 7,533 1,675 6,894 0 826 43.00


50.00 05000 OPERATING ROOM 98,331 32,730 203,744 8,644 24,405 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 14,755 0 29,935 4,621 3,586 52.00

53.00 05300 ANESTHESIOLOGY 9,605 2,752 40,071 0 4,800 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 41,345 15,617 69,397 0 8,312 54.00

54.01 05401 ULTRASOUND 7,779 898 7,313 0 876 54.01

54.03 05403 CARDIOVASCULAR LAB 42,008 6,043 75,550 1,856 9,049 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 37,596 13,044 232,841 0 27,890 55.00

55.01 05501 CHEMOTHERAPY 11,459 2,334 104,266 0 12,489 55.01

56.01 05601 NUCLEAR MEDICINE 15,862 479 9,761 0 1,169 56.01

57.00 05700 CT SCAN 20,855 7,120 20,838 0 2,496 57.00

58.00 05800 MRI 11,378 2,154 23,802 0 2,851 58.00

60.00 06000 LABORATORY 89,923 15,019 70,596 0 8,456 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 8,437 539 1,609 0 193 63.00

65.00 06500 RESPIRATORY THERAPY 24,663 3,231 13,656 0 1,636 65.00

66.00 06600 PHYSICAL THERAPY 9,613 2,633 8,522 0 1,021 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 22,514 0 75,052 0 8,990 66.01

66.02 06602 PHYSIATRY 0 0 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 2,459 1,795 1,755 0 210 67.00


69.01 06901 CV DIAGNOSTIC 15,890 1,616 6,830 0 818 69.01


70.01 07001 NEUROPHYSIOLOGY 8,998 3,231 22,052 0 2,641 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 103,566 0 0 0 0 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 159,951 0 0 0 0 72.00


MCRIF32 - 8.8.159.0 70 | Page


Date/Time Prepared:

Worksheet B

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



ADMINISTRATIV

E & GENERAL

MAINTENANCE &

REPAIRS

OPERATION OF

PLANT

LAUNDRY &

LINEN SERVICE

HOUSEKEEPING

5.06 6.00 7.00 8.00 9.00

73.00 07300 DRUGS CHARGED TO PATIENTS 176,991 2,693 20,867 0 2,499 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 3,595 2,812 7,167 0 858 76.97


76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99



88.01 08801 RURAL HEALTH CLINIC II 27,570 5,983 82,882 0 9,928 88.01

88.02 08802 RURAL HEALTH CLINIC III 22,864 4,966 55,253 0 6,618 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 5,636 4,308 0 0 0 90.01

90.02 09002 DIABETES CENTER 2,584 2,393 24,377 0 2,920 90.02

91.00 09100 EMERGENCY 54,656 32,490 59,495 142 7,126 91.00

91.01 09101 G.I. LABORATORY 12,215 7,120 40,359 653 4,834 91.01



101.00 10100 HOME HEALTH AGENCY 13,203 2,453 16,021 0 1,919 101.00



116.00 11600 HOSPICE 17,526 3,650 16,021 0 1,919 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 1,521,563 580,878 2,230,190 100,244 262,986 118.00


190.00 19000 GIFT, FLOWER, COFFEE SHOP & CANTEEN 379 2,274 10,999 0 1,317 190.00

191.01 19101 RESPITE CARE 0 0 0 0 0 191.01



193.03 19303 LACEYS RESTAURANT 749 8,197 19,014 0 2,278 193.03


193.05 19305 HOME INFUSION 0 0 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 274,986 54,031 170,528 0 20,426 193.06

193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 47,195 1,137 9,507 0 1,139 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 24,972 6,343 27,376 0 3,279 193.11

193.13 19313 HEALTHPOINT 25,070 2,154 256,009 0 30,665 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14

194.00 07950 JAZZMANS RESTAURANT 587 658 2,472 0 296 194.00

194.01 07951 FOUNDATION OFFICE 789 2,094 24,402 0 2,923 194.01



202.00 TOTAL (sum lines 118-201) 1,897,879 657,766 2,750,497 100,244 325,309 202.00


MCRIF32 - 8.8.159.0 71 | Page


Date/Time Prepared:

Worksheet B

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Cost Center Description DIETARY CAFETERIA MAINTENANCE

OF PERSONNEL

NURSING

ADMINISTRATIO

N

CENTRAL

SERVICES &

SUPPLY

10.00 11.00 12.00 13.00 14.00


















5.04 00570 ADMITTING 5.04







10.00 01000 DIETARY 564,448 10.00

11.00 01100 CAFETERIA 293,864 293,864 11.00

12.00 01200 MAINTENANCE OF PERSONNEL 0 0 0 12.00

13.00 01300 NURSING ADMINISTRATION 0 10,755 0 772,153 13.00

14.00 01400 CENTRAL SERVICES & SUPPLY 0 5,130 0 0 583,482 14.00

15.00 01500 PHARMACY 0 0 0 0 0 15.00


17.00 01700 SOCIAL SERVICE 0 0 0 0 0 17.00


20.00 02000 NURSING SCHOOL 0 6,008 0 0 0 20.00








30.00 03000 ADULTS & PEDIATRICS 211,005 55,668 0 485,740 12,953 30.00

33.01 03301 ADULT SPECIAL CARE 9,140 6,761 0 58,057 6,228 33.01

34.01 03401 CARDIOTHORACIC ICU 9,363 5,076 0 44,510 2,448 34.01

40.00 04000 SUBPROVIDER - IPF 22,451 4,271 0 36,769 106 40.00

41.00 04100 SUBPROVIDER - IRF 16,537 3,586 0 30,964 327 41.00

43.00 04300 NURSERY 0 1,960 0 17,417 460 43.00


50.00 05000 OPERATING ROOM 697 16,645 0 0 121,458 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0 4,393 0 0 2,016 52.00

53.00 05300 ANESTHESIOLOGY 0 5,717 0 0 11,239 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0 10,182 0 0 12,102 54.00

54.01 05401 ULTRASOUND 0 1,558 0 0 679 54.01

54.03 05403 CARDIOVASCULAR LAB 96 4,783 0 0 57,126 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0 4,093 0 0 1,963 55.00

55.01 05501 CHEMOTHERAPY 0 2,816 0 0 1,442 55.01

56.01 05601 NUCLEAR MEDICINE 218 1,009 0 0 45 56.01

57.00 05700 CT SCAN 0 1,974 0 0 2,474 57.00

58.00 05800 MRI 0 1,047 0 0 205 58.00

60.00 06000 LABORATORY 0 20,050 0 0 41,993 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0 2 0 0 2,186 63.00

65.00 06500 RESPIRATORY THERAPY 0 6,547 0 0 5,521 65.00

66.00 06600 PHYSICAL THERAPY 0 2,814 0 0 34 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0 7,411 0 0 244 66.01

66.02 06602 PHYSIATRY 0 0 0 0 0 66.02



69.01 06901 CV DIAGNOSTIC 0 3,053 0 0 342 69.01


70.01 07001 NEUROPHYSIOLOGY 28 2,082 0 0 1,477 70.01


72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0 0 0 0 279,798 72.00


MCRIF32 - 8.8.159.0 72 | Page


Date/Time Prepared:

Worksheet B

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Cost Center Description DIETARY CAFETERIA MAINTENANCE

OF PERSONNEL

NURSING

ADMINISTRATIO

N

CENTRAL

SERVICES &

SUPPLY

10.00 11.00 12.00 13.00 14.00

73.00 07300 DRUGS CHARGED TO PATIENTS 0 6,742 0 0 0 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 0 1,389 0 11,611 26 76.97


76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99



88.01 08801 RURAL HEALTH CLINIC II 0 5,496 0 0 293 88.01

88.02 08802 RURAL HEALTH CLINIC III 0 3,297 0 0 640 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 0 1,706 0 0 587 90.01

90.02 09002 DIABETES CENTER 0 645 0 5,806 5 90.02

91.00 09100 EMERGENCY 1,049 17,758 0 0 9,246 91.00

91.01 09101 G.I. LABORATORY 0 1,873 0 0 3,701 91.01



101.00 10100 HOME HEALTH AGENCY 0 0 0 29,028 310 101.00



116.00 11600 HOSPICE 0 0 0 34,834 239 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 564,448 236,602 0 754,736 579,944 118.00



191.01 19101 RESPITE CARE 0 0 0 0 0 191.01





193.05 19305 HOME INFUSION 0 0 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 0 45,503 0 1,935 3,538 193.06

193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 0 1,546 0 0 0 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 0 2,689 0 0 0 193.11

193.13 19313 HEALTHPOINT 0 7,219 0 15,482 0 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14





202.00 TOTAL (sum lines 118-201) 564,448 293,864 0 772,153 583,482 202.00


MCRIF32 - 8.8.159.0 73 | Page


Date/Time Prepared:

Worksheet B

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Cost Center Description PHARMACY MEDICAL

RECORDS &

LIBRARY

SOCIAL

SERVICE

NONPHYSICIAN

ANESTHETISTS

NURSING

SCHOOL

15.00 16.00 17.00 19.00 20.00


















5.04 00570 ADMITTING 5.04







10.00 01000 DIETARY 10.00

11.00 01100 CAFETERIA 11.00




15.00 01500 PHARMACY 0 15.00


17.00 01700 SOCIAL SERVICE 0 0 0 17.00

19.00 01900 NONPHYSICIAN ANESTHETISTS 0 0 0 0 19.00

20.00 02000 NURSING SCHOOL 0 0 0 370,850 20.00

20.01 02001 SCHOOL OF MEDICAL TECHNOLOGY 0 0 0 20.01

20.02 02002 SCHOOL OF SURGICAL TECHNOLOGY 0 0 0 20.02

20.03 02003 SCHOOL OF RADIOLOGICAL TECHNOLO 0 0 0 20.03

21.00 02100 I&R SERVICES-SALARY & FRINGES APPRV 0 0 0 21.00

22.00 02200 I&R SERVICES-OTHER PRGM COSTS APPRV 0 0 0 22.00

23.00 02300 PARAMEDICAL EDUCATION PROGRAM 0 0 0 23.00


30.00 03000 ADULTS & PEDIATRICS 0 0 0 30.00

33.01 03301 ADULT SPECIAL CARE 0 0 0 33.01

34.01 03401 CARDIOTHORACIC ICU 0 0 0 34.01

40.00 04000 SUBPROVIDER - IPF 0 0 0 40.00

41.00 04100 SUBPROVIDER - IRF 0 0 0 41.00

43.00 04300 NURSERY 0 0 0 43.00


50.00 05000 OPERATING ROOM 0 0 0 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0 0 0 52.00

53.00 05300 ANESTHESIOLOGY 0 0 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0 0 0 54.00

54.01 05401 ULTRASOUND 0 0 0 54.01

54.03 05403 CARDIOVASCULAR LAB 0 0 0 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0 0 0 55.00

55.01 05501 CHEMOTHERAPY 0 0 0 55.01

56.01 05601 NUCLEAR MEDICINE 0 0 0 56.01

57.00 05700 CT SCAN 0 0 0 57.00

58.00 05800 MRI 0 0 0 58.00

60.00 06000 LABORATORY 0 0 0 60.00

62.30 06250 BLOOD CLOTTING FACTORS FOR HEMOPH. 0 0 0 62.30

63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0 0 0 63.00

65.00 06500 RESPIRATORY THERAPY 0 0 0 65.00

66.00 06600 PHYSICAL THERAPY 0 0 0 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0 0 0 66.01

66.02 06602 PHYSIATRY 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 0 0 0 67.00

68.00 06800 SPEECH PATHOLOGY 0 0 0 68.00

69.01 06901 CV DIAGNOSTIC 0 0 0 69.01

69.02 06902 ELECTROPHYSIOLOGY LAB 0 0 0 69.02

70.01 07001 NEUROPHYSIOLOGY 0 0 0 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 0 0 0 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0 0 0 72.00


MCRIF32 - 8.8.159.0 74 | Page


Date/Time Prepared:

Worksheet B

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Cost Center Description PHARMACY MEDICAL

RECORDS &

LIBRARY

SOCIAL

SERVICE

NONPHYSICIAN

ANESTHETISTS

NURSING

SCHOOL

15.00 16.00 17.00 19.00 20.00

73.00 07300 DRUGS CHARGED TO PATIENTS 0 0 0 73.00

76.00 03950 CARDIAC REHAB 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 0 0 0 76.97

76.98 07698 HYPERBARIC OXYGEN THERAPY 0 0 0 76.98

76.99 07699 LITHOTRIPSY 0 0 0 76.99


88.00 08800 RURAL HEALTH CLINIC 0 0 0 88.00

88.01 08801 RURAL HEALTH CLINIC II 0 0 0 88.01

88.02 08802 RURAL HEALTH CLINIC III 0 0 0 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 0 0 0 90.01

90.02 09002 DIABETES CENTER 0 0 0 90.02

91.00 09100 EMERGENCY 0 0 0 91.00

91.01 09101 G.I. LABORATORY 0 0 0 91.01



101.00 10100 HOME HEALTH AGENCY 0 0 0 101.00



116.00 11600 HOSPICE 0 0 0 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 0 0 0 0 0 118.00


190.00 19000 GIFT, FLOWER, COFFEE SHOP & CANTEEN 0 0 0 190.00

191.01 19101 RESPITE CARE 0 0 0 191.01

193.01 19301 VENDING MACHINES 0 0 0 193.01

193.02 19302 SUNSET GUEST HOUSE 0 0 0 193.02

193.03 19303 LACEYS RESTAURANT 0 0 0 193.03

193.04 19304 COMMUNITY WELLNESS 0 0 0 193.04

193.05 19305 HOME INFUSION 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 0 0 0 193.06

193.07 19307 GENERATIONS 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 0 0 0 193.08

193.09 19309 OUTREACH LAB 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 193.10

193.11 19311 MARKETING 0 0 0 193.11

193.13 19313 HEALTHPOINT 0 0 0 193.13

193.14 19314 DOCTORS PARK 0 0 0 193.14

194.00 07950 JAZZMANS RESTAURANT 0 0 0 194.00

194.01 07951 FOUNDATION OFFICE 0 0 0 194.01

200.00 Cross Foot Adjustments 0 370,850 200.00


202.00 TOTAL (sum lines 118-201) 0 0 0 0 370,850 202.00


MCRIF32 - 8.8.159.0 75 | Page


Date/Time Prepared:

Worksheet B

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


INTERNS & RESIDENTS

Cost Center Description SCHOOL OF

MEDICAL

TECHNOLOGY

SCHOOL OF

SURGICAL

TECHNOLOGY

SCHOOL OF

RADIOLOGICAL

TECHNOLO

SERVICES-SALA

RY & FRINGES

APPRV

SERVICES-OTHE

R PRGM COSTS

APPRV

20.01 20.02 20.03 21.00 22.00


















5.04 00570 ADMITTING 5.04







10.00 01000 DIETARY 10.00

11.00 01100 CAFETERIA 11.00




15.00 01500 PHARMACY 15.00












30.00 03000 ADULTS & PEDIATRICS 30.00

33.01 03301 ADULT SPECIAL CARE 33.01

34.01 03401 CARDIOTHORACIC ICU 34.01

40.00 04000 SUBPROVIDER - IPF 40.00

41.00 04100 SUBPROVIDER - IRF 41.00

43.00 04300 NURSERY 43.00


50.00 05000 OPERATING ROOM 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 52.00

53.00 05300 ANESTHESIOLOGY 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 54.00

54.01 05401 ULTRASOUND 54.01

54.03 05403 CARDIOVASCULAR LAB 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 55.00

55.01 05501 CHEMOTHERAPY 55.01

56.01 05601 NUCLEAR MEDICINE 56.01

57.00 05700 CT SCAN 57.00

58.00 05800 MRI 58.00

60.00 06000 LABORATORY 60.00

62.30 06250 BLOOD CLOTTING FACTORS FOR HEMOPH. 62.30

63.00 06300 BLOOD STORING, PROCESSING & TRANS. 63.00

65.00 06500 RESPIRATORY THERAPY 65.00

66.00 06600 PHYSICAL THERAPY 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 66.01

66.02 06602 PHYSIATRY 66.02

67.00 06700 OCCUPATIONAL THERAPY 67.00

68.00 06800 SPEECH PATHOLOGY 68.00

69.01 06901 CV DIAGNOSTIC 69.01

69.02 06902 ELECTROPHYSIOLOGY LAB 69.02

70.01 07001 NEUROPHYSIOLOGY 70.01


MCRIF32 - 8.8.159.0 76 | Page


Date/Time Prepared:

Worksheet B

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


INTERNS & RESIDENTS


MEDICAL

TECHNOLOGY

SCHOOL OF

SURGICAL

TECHNOLOGY

SCHOOL OF

RADIOLOGICAL

TECHNOLO

SERVICES-SALA

RY & FRINGES

APPRV

SERVICES-OTHE

R PRGM COSTS

APPRV

20.01 20.02 20.03 21.00 22.00

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 73.00

76.00 03950 CARDIAC REHAB 76.00

76.97 07697 CARDIAC REHABILITATION 76.97

76.98 07698 HYPERBARIC OXYGEN THERAPY 76.98

76.99 07699 LITHOTRIPSY 76.99


88.00 08800 RURAL HEALTH CLINIC 88.00

88.01 08801 RURAL HEALTH CLINIC II 88.01

88.02 08802 RURAL HEALTH CLINIC III 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 90.01

90.02 09002 DIABETES CENTER 90.02

91.00 09100 EMERGENCY 91.00

91.01 09101 G.I. LABORATORY 91.01



101.00 10100 HOME HEALTH AGENCY 101.00



116.00 11600 HOSPICE 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 0 0 0 0 0 118.00


190.00 19000 GIFT, FLOWER, COFFEE SHOP & CANTEEN 190.00

191.01 19101 RESPITE CARE 191.01

193.01 19301 VENDING MACHINES 193.01

193.02 19302 SUNSET GUEST HOUSE 193.02

193.03 19303 LACEYS RESTAURANT 193.03

193.04 19304 COMMUNITY WELLNESS 193.04

193.05 19305 HOME INFUSION 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 193.06

193.07 19307 GENERATIONS 193.07

193.08 19308 RETAIL PHARMACY 193.08

193.09 19309 OUTREACH LAB 193.09

193.10 19310 FOOT CLINIC 193.10

193.11 19311 MARKETING 193.11

193.13 19313 HEALTHPOINT 193.13

193.14 19314 DOCTORS PARK 193.14

194.00 07950 JAZZMANS RESTAURANT 194.00

194.01 07951 FOUNDATION OFFICE 194.01

200.00 Cross Foot Adjustments 26,879 23,654 53,715 0 0 200.00


202.00 TOTAL (sum lines 118-201) 26,879 23,654 53,715 0 0 202.00


MCRIF32 - 8.8.159.0 77 | Page


Date/Time Prepared:

Worksheet B

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Cost Center Description PARAMEDICAL

EDUCATION

PROGRAM

Subtotal Intern &

Residents

Cost & Post

Stepdown

Adjustments

Total

23.00 24.00 25.00 26.00


















5.04 00570 ADMITTING 5.04







10.00 01000 DIETARY 10.00

11.00 01100 CAFETERIA 11.00




15.00 01500 PHARMACY 15.00












30.00 03000 ADULTS & PEDIATRICS 4,790,998 0 4,790,998 30.00

33.01 03301 ADULT SPECIAL CARE 643,630 0 643,630 33.01

34.01 03401 CARDIOTHORACIC ICU 847,937 0 847,937 34.01

40.00 04000 SUBPROVIDER - IPF 346,718 0 346,718 40.00

41.00 04100 SUBPROVIDER - IRF 377,716 0 377,716 41.00

43.00 04300 NURSERY 154,104 0 154,104 43.00


50.00 05000 OPERATING ROOM 3,121,731 0 3,121,731 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 273,222 0 273,222 52.00

53.00 05300 ANESTHESIOLOGY 511,168 0 511,168 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 1,254,660 0 1,254,660 54.00

54.01 05401 ULTRASOUND 185,287 0 185,287 54.01

54.03 05403 CARDIOVASCULAR LAB 1,548,955 0 1,548,955 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 2,536,760 0 2,536,760 55.00

55.01 05501 CHEMOTHERAPY 594,845 0 594,845 55.01

56.01 05601 NUCLEAR MEDICINE 273,525 0 273,525 56.01

57.00 05700 CT SCAN 1,127,280 0 1,127,280 57.00

58.00 05800 MRI 625,989 0 625,989 58.00

60.00 06000 LABORATORY 1,306,909 0 1,306,909 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 59,258 0 59,258 63.00

65.00 06500 RESPIRATORY THERAPY 421,144 0 421,144 65.00

66.00 06600 PHYSICAL THERAPY 120,450 0 120,450 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 501,699 0 501,699 66.01

66.02 06602 PHYSIATRY 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 29,703 0 29,703 67.00

68.00 06800 SPEECH PATHOLOGY 16,585 0 16,585 68.00

69.01 06901 CV DIAGNOSTIC 219,030 0 219,030 69.01


70.01 07001 NEUROPHYSIOLOGY 263,619 0 263,619 70.01


MCRIF32 - 8.8.159.0 78 | Page


Date/Time Prepared:

Worksheet B

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



EDUCATION

PROGRAM

Subtotal Intern &

Residents

Cost & Post

Stepdown

Adjustments

Total

23.00 24.00 25.00 26.00

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 560,974 0 560,974 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 1,214,779 0 1,214,779 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 1,536,566 0 1,536,566 73.00

76.00 03950 CARDIAC REHAB 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 101,048 0 101,048 76.97


76.99 07699 LITHOTRIPSY 0 0 0 76.99



88.01 08801 RURAL HEALTH CLINIC II 568,489 0 568,489 88.01

88.02 08802 RURAL HEALTH CLINIC III 401,278 0 401,278 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 79,253 0 79,253 90.01

90.02 09002 DIABETES CENTER 138,954 0 138,954 90.02

91.00 09100 EMERGENCY 1,173,426 0 1,173,426 91.00

91.01 09101 G.I. LABORATORY 665,439 0 665,439 91.01



101.00 10100 HOME HEALTH AGENCY 222,952 0 222,952 101.00



116.00 11600 HOSPICE 238,862 0 238,862 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 0 29,054,942 0 29,054,942 118.00


190.00 19000 GIFT, FLOWER, COFFEE SHOP & CANTEEN 59,235 0 59,235 190.00

191.01 19101 RESPITE CARE 0 0 0 191.01

193.01 19301 VENDING MACHINES 0 0 0 193.01

193.02 19302 SUNSET GUEST HOUSE 0 0 0 193.02

193.03 19303 LACEYS RESTAURANT 104,892 0 104,892 193.03

193.04 19304 COMMUNITY WELLNESS 8,163 0 8,163 193.04

193.05 19305 HOME INFUSION 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 1,805,201 0 1,805,201 193.06

193.07 19307 GENERATIONS 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 314,587 0 314,587 193.08

193.09 19309 OUTREACH LAB 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 193.10

193.11 19311 MARKETING 293,011 0 293,011 193.11

193.13 19313 HEALTHPOINT 1,418,760 0 1,418,760 193.13

193.14 19314 DOCTORS PARK 0 0 0 193.14

194.00 07950 JAZZMANS RESTAURANT 25,797 0 25,797 194.00

194.01 07951 FOUNDATION OFFICE 120,964 0 120,964 194.01

200.00 Cross Foot Adjustments 0 475,098 0 475,098 200.00


202.00 TOTAL (sum lines 118-201) 0 33,680,650 0 33,680,650 202.00


MCRIF32 - 8.8.159.0 79 | Page


Date/Time Prepared:

Worksheet B-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110COST ALLOCATION - STATISTICAL BASIS


Cost Center Description BLDG & FIXT

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #2

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #3

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #4

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #5

(SQUARE FEET)

1.00 1.01 1.02 1.03 1.04


1.00 00100 CAP REL COSTS-BLDG & FIXT 17,920 1.00












4.00 00400 EMPLOYEE BENEFITS DEPARTMENT 0 0 0 0 0 4.00

5.01 01160 COMMUNICATIONS 192 0 0 0 0 5.01

5.02 00550 DATA PROCESSING 0 738 138 0 0 5.02

5.03 00560 PURCHASING RECEIVING AND STORES 0 1,200 4,032 0 0 5.03

5.04 00570 ADMITTING 0 3,869 0 2,496 0 5.04

5.05 00580 CASHIERING/ACCOUNTS RECEIVABLE 620 0 0 1,009 0 5.05

5.06 00590 OTHER ADMINISTRATIVE & GENERAL 2,728 3,649 0 7,049 0 5.06

6.00 00600 MAINTENANCE & REPAIRS 0 0 1,056 5,288 0 6.00

7.00 00700 OPERATION OF PLANT 1,144 2,330 3,294 1,970 0 7.00


9.00 00900 HOUSEKEEPING 0 1,710 538 350 0 9.00

10.00 01000 DIETARY 0 3,826 0 9,142 0 10.00

11.00 01100 CAFETERIA 0 0 0 0 0 11.00


13.00 01300 NURSING ADMINISTRATION 2,215 2,900 483 0 0 13.00

14.00 01400 CENTRAL SERVICES & SUPPLY 0 200 0 0 0 14.00

15.00 01500 PHARMACY 0 0 0 0 0 15.00


17.00 01700 SOCIAL SERVICE 0 0 0 0 0 17.00


20.00 02000 NURSING SCHOOL 0 0 0 0 0 20.00








30.00 03000 ADULTS & PEDIATRICS 2,356 12,772 25,428 12,075 0 30.00


34.01 03401 CARDIOTHORACIC ICU 0 0 0 0 0 34.01

40.00 04000 SUBPROVIDER - IPF 0 0 5,244 0 0 40.00

41.00 04100 SUBPROVIDER - IRF 0 8,021 0 0 0 41.00

43.00 04300 NURSERY 0 0 0 1,414 0 43.00


50.00 05000 OPERATING ROOM 0 0 0 0 0 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0 3,504 0 2,637 0 52.00

53.00 05300 ANESTHESIOLOGY 0 1,024 0 0 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0 0 0 0 0 54.00

54.01 05401 ULTRASOUND 0 0 0 0 0 54.01

54.03 05403 CARDIOVASCULAR LAB 0 0 0 0 0 54.03


55.01 05501 CHEMOTHERAPY 0 0 0 0 0 55.01


57.00 05700 CT SCAN 0 0 0 0 0 57.00

58.00 05800 MRI 0 0 0 0 0 58.00

60.00 06000 LABORATORY 0 0 0 0 0 60.00



65.00 06500 RESPIRATORY THERAPY 1,134 0 0 0 0 65.00



66.02 06602 PHYSIATRY 0 0 0 0 0 66.02



69.01 06901 CV DIAGNOSTIC 0 0 0 0 0 69.01



MCRIF32 - 8.8.159.0 80 | Page


Date/Time Prepared:

Worksheet B-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015




(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #2

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #3

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #4

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #5

(SQUARE FEET)

1.00 1.01 1.02 1.03 1.04

70.01 07001 NEUROPHYSIOLOGY 3,411 0 0 0 0 70.01



73.00 07300 DRUGS CHARGED TO PATIENTS 4,120 0 0 0 0 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00



76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99






90.02 09002 DIABETES CENTER 0 0 0 0 0 90.02

91.00 09100 EMERGENCY 0 0 0 0 0 91.00

91.01 09101 G.I. LABORATORY 0 8,278 0 0 0 91.01



101.00 10100 HOME HEALTH AGENCY 0 0 0 0 0 101.00



116.00 11600 HOSPICE 0 0 0 0 0 116.00




191.01 19101 RESPITE CARE 0 0 0 0 0 191.01





193.05 19305 HOME INFUSION 0 0 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 0 386 0 1,184 0 193.06

193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 0 0 0 0 0 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 0 0 0 0 0 193.11

193.13 19313 HEALTHPOINT 0 0 0 0 0 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14




201.00 Negative Cost Centers 201.00

202.00 Cost to be allocated (per Wkst. B,

Part I)

277,399 304,510 603,866 336,528 0 202.00

203.00 Unit cost multiplier (Wkst. B, Part I) 15.479855 5.563249 14.830808 7.516148 0.000000 203.00


Part II)

204.00

205.00 Unit cost multiplier (Wkst. B, Part

II)

205.00


MCRIF32 - 8.8.159.0 81 | Page


Date/Time Prepared:

Worksheet B-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015




CSTS-BLDGS &

FIX #6

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #7

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #8

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #9

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #1

(SQUARE FEE

T)

1.05 1.06 1.07 1.08 1.09







1.05 00105 NEW CAP-REL CSTS-BLDGS & FIX #6 15,922 1.05







4.00 00400 EMPLOYEE BENEFITS DEPARTMENT 4,701 0 0 4,701 0 4.00

5.01 01160 COMMUNICATIONS 0 468 0 660 0 5.01

5.02 00550 DATA PROCESSING 694 1,524 0 3,094 0 5.02

5.03 00560 PURCHASING RECEIVING AND STORES 0 0 0 5,232 0 5.03

5.04 00570 ADMITTING 1,264 0 0 7,629 0 5.04

5.05 00580 CASHIERING/ACCOUNTS RECEIVABLE 0 0 0 1,835 0 5.05

5.06 00590 OTHER ADMINISTRATIVE & GENERAL 870 1,762 314 16,472 0 5.06

6.00 00600 MAINTENANCE & REPAIRS 0 0 8,764 15,108 0 6.00

7.00 00700 OPERATION OF PLANT 1,944 15,840 0 31,269 0 7.00

8.00 00800 LAUNDRY & LINEN SERVICE 0 64 128 3,781 0 8.00

9.00 00900 HOUSEKEEPING 340 160 230 3,328 0 9.00

10.00 01000 DIETARY 0 0 0 12,968 0 10.00

11.00 01100 CAFETERIA 0 0 0 0 0 11.00


13.00 01300 NURSING ADMINISTRATION 4,639 358 0 13,880 0 13.00

14.00 01400 CENTRAL SERVICES & SUPPLY 0 0 0 3,948 0 14.00

15.00 01500 PHARMACY 0 0 0 0 0 15.00


17.00 01700 SOCIAL SERVICE 0 0 0 0 0 17.00


20.00 02000 NURSING SCHOOL 0 0 0 14,088 0 20.00

20.01 02001 SCHOOL OF MEDICAL TECHNOLOGY 0 0 0 1,011 0 20.01







30.00 03000 ADULTS & PEDIATRICS 0 30,198 0 82,830 0 30.00

33.01 03301 ADULT SPECIAL CARE 0 10,658 0 10,658 0 33.01

34.01 03401 CARDIOTHORACIC ICU 0 0 18,080 18,080 0 34.01

40.00 04000 SUBPROVIDER - IPF 0 0 0 5,244 0 40.00

41.00 04100 SUBPROVIDER - IRF 0 0 0 8,021 0 41.00

43.00 04300 NURSERY 0 0 0 1,414 0 43.00


50.00 05000 OPERATING ROOM 0 16,962 21,083 41,790 0 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0 0 0 6,140 0 52.00

53.00 05300 ANESTHESIOLOGY 0 0 7,195 8,219 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0 0 2,147 14,234 0 54.00

54.01 05401 ULTRASOUND 0 0 1,500 1,500 0 54.01

54.03 05403 CARDIOVASCULAR LAB 0 4,584 5,634 15,496 0 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0 0 21,436 47,758 0 55.00

55.01 05501 CHEMOTHERAPY 0 0 0 21,386 0 55.01

56.01 05601 NUCLEAR MEDICINE 0 0 2,002 2,002 0 56.01

57.00 05700 CT SCAN 0 0 1,104 4,274 0 57.00

58.00 05800 MRI 0 0 0 4,882 0 58.00

60.00 06000 LABORATORY 0 9,081 1,022 14,480 0 60.00



65.00 06500 RESPIRATORY THERAPY 0 0 1,667 2,801 0 65.00

66.00 06600 PHYSICAL THERAPY 0 1,748 0 1,748 0 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0 0 0 15,394 0 66.01

66.02 06602 PHYSIATRY 0 0 0 0 0 66.02



69.01 06901 CV DIAGNOSTIC 0 880 521 1,401 0 69.01


MCRIF32 - 8.8.159.0 82 | Page


Date/Time Prepared:

Worksheet B-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015




CSTS-BLDGS &

FIX #6

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #7

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #8

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #9

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #1

(SQUARE FEE

T)

1.05 1.06 1.07 1.08 1.09


70.01 07001 NEUROPHYSIOLOGY 0 499 0 4,523 0 70.01



73.00 07300 DRUGS CHARGED TO PATIENTS 0 0 160 4,280 0 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 1,470 0 0 1,470 0 76.97


76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99



88.01 08801 RURAL HEALTH CLINIC II 0 0 0 17,000 0 88.01

88.02 08802 RURAL HEALTH CLINIC III 0 0 0 11,333 0 88.02


90.02 09002 DIABETES CENTER 0 0 0 5,000 0 90.02

91.00 09100 EMERGENCY 0 0 12,203 12,203 0 91.00

91.01 09101 G.I. LABORATORY 0 0 0 8,278 0 91.01



101.00 10100 HOME HEALTH AGENCY 0 0 0 3,286 0 101.00



116.00 11600 HOSPICE 0 0 0 3,286 0 116.00




191.01 19101 RESPITE CARE 0 0 0 0 0 191.01



193.03 19303 LACEYS RESTAURANT 0 0 0 3,900 0 193.03


193.05 19305 HOME INFUSION 0 0 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 0 0 0 34,977 0 193.06

193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 0 0 0 1,950 0 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 0 0 0 5,615 0 193.11

193.13 19313 HEALTHPOINT 0 0 0 52,510 0 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14


194.01 07951 FOUNDATION OFFICE 0 0 0 5,005 0 194.01




Part I)

217,366 490,924 852,103 11,287,789 0 202.00



Part II)

204.00


II)

205.00


MCRIF32 - 8.8.159.0 83 | Page


Date/Time Prepared:

Worksheet B-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015




CSTS-BLDGS &

FIX #1

(SQUARE FEE

T)

MVBLE EQUIP

(DIRECT COS

TS)

EMPLOYEE

BENEFITS

DEPARTMENT

(GROSS

SALARIES)

COMMUNICATION

S

(NONPATIENT)

Reconciliatio

n

1.10 2.00 4.00 5.01 5A.02














4.00 00400 EMPLOYEE BENEFITS DEPARTMENT 0 92,746 90,088,755 4.00

5.01 01160 COMMUNICATIONS 0 99,915 0 2,658 5.01

5.02 00550 DATA PROCESSING 0 7,684,710 0 43 -12,613,251 5.02

5.03 00560 PURCHASING RECEIVING AND STORES 0 81,256 673,588 22 0 5.03

5.04 00570 ADMITTING 0 3,592 1,850,575 82 0 5.04

5.05 00580 CASHIERING/ACCOUNTS RECEIVABLE 0 142,075 677,048 74 0 5.05

5.06 00590 OTHER ADMINISTRATIVE & GENERAL 0 261,729 2,030,394 256 0 5.06

6.00 00600 MAINTENANCE & REPAIRS 0 74,651 1,325,753 32 0 6.00

7.00 00700 OPERATION OF PLANT 0 134,533 0 0 0 7.00


9.00 00900 HOUSEKEEPING 0 48,660 1,958,009 19 0 9.00

10.00 01000 DIETARY 0 14,771 1,168,176 25 0 10.00

11.00 01100 CAFETERIA 0 0 0 0 0 11.00


13.00 01300 NURSING ADMINISTRATION 0 98,440 2,294,347 52 0 13.00

14.00 01400 CENTRAL SERVICES & SUPPLY 0 101,842 817,399 15 0 14.00

15.00 01500 PHARMACY 0 0 0 0 0 15.00


17.00 01700 SOCIAL SERVICE 0 0 0 0 0 17.00


20.00 02000 NURSING SCHOOL 0 9,885 1,613,783 42 0 20.00

20.01 02001 SCHOOL OF MEDICAL TECHNOLOGY 0 1,132 125,210 0 0 20.01

20.02 02002 SCHOOL OF SURGICAL TECHNOLOGY 0 541 48,894 0 0 20.02

20.03 02003 SCHOOL OF RADIOLOGICAL TECHNOLO 0 579 156,178 0 0 20.03





30.00 03000 ADULTS & PEDIATRICS 0 329,210 10,618,692 437 0 30.00

33.01 03301 ADULT SPECIAL CARE 0 47,728 1,728,544 40 0 33.01

34.01 03401 CARDIOTHORACIC ICU 0 90,737 1,176,956 28 0 34.01

40.00 04000 SUBPROVIDER - IPF 0 7,618 834,694 17 0 40.00

41.00 04100 SUBPROVIDER - IRF 0 12,475 835,519 33 0 41.00

43.00 04300 NURSERY 0 48,238 618,463 10 0 43.00


50.00 05000 OPERATING ROOM 0 1,024,066 4,477,564 134 0 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0 0 1,063,846 0 0 52.00

53.00 05300 ANESTHESIOLOGY 0 162,748 214,622 27 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0 619,978 2,336,021 144 0 54.00

54.01 05401 ULTRASOUND 0 90,635 478,610 6 0 54.01

54.03 05403 CARDIOVASCULAR LAB 0 532,119 1,333,038 34 0 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0 1,058,979 1,216,666 38 0 55.00

55.01 05501 CHEMOTHERAPY 0 36,967 637,163 8 0 55.01

56.01 05601 NUCLEAR MEDICINE 0 120,714 321,035 12 0 56.01

57.00 05700 CT SCAN 0 887,414 530,377 10 0 57.00

58.00 05800 MRI 0 447,658 335,198 19 0 58.00

60.00 06000 LABORATORY 0 319,858 3,666,986 77 0 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0 1,792 745 6 0 63.00

65.00 06500 RESPIRATORY THERAPY 0 88,260 1,492,426 22 0 65.00

66.00 06600 PHYSICAL THERAPY 0 12,338 808,337 13 0 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0 15,622 1,735,819 77 0 66.01

66.02 06602 PHYSIATRY 0 0 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 0 3,221 209,647 0 0 67.00

68.00 06800 SPEECH PATHOLOGY 0 774 154,951 2 0 68.00

69.01 06901 CV DIAGNOSTIC 0 77,631 728,677 45 0 69.01


MCRIF32 - 8.8.159.0 84 | Page


Date/Time Prepared:

Worksheet B-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015




CSTS-BLDGS &

FIX #1

(SQUARE FEE

T)

MVBLE EQUIP

(DIRECT COS

TS)

EMPLOYEE

BENEFITS

DEPARTMENT

(GROSS

SALARIES)

COMMUNICATION

S

(NONPATIENT)

Reconciliatio

n

1.10 2.00 4.00 5.01 5A.02


70.01 07001 NEUROPHYSIOLOGY 0 38,891 479,601 29 0 70.01



73.00 07300 DRUGS CHARGED TO PATIENTS 0 19,849 2,397,492 22 0 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 0 11,567 387,897 13 0 76.97


76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99



88.01 08801 RURAL HEALTH CLINIC II 0 20,610 2,125,400 48 0 88.01

88.02 08802 RURAL HEALTH CLINIC III 0 12,078 1,530,004 15 0 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 0 40,481 315,751 24 0 90.01

90.02 09002 DIABETES CENTER 0 1,856 161,555 13 0 90.02

91.00 09100 EMERGENCY 0 319,353 3,193,430 77 0 91.00

91.01 09101 G.I. LABORATORY 0 139,658 524,174 24 0 91.01



101.00 10100 HOME HEALTH AGENCY 0 7,404 1,056,799 33 0 101.00



116.00 11600 HOSPICE 0 324 1,142,928 37 0 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 0 15,499,908 65,608,981 2,236 -12,613,251 118.00



191.01 19101 RESPITE CARE 0 0 0 0 0 191.01



193.03 19303 LACEYS RESTAURANT 0 3,482 0 9 0 193.03

193.04 19304 COMMUNITY WELLNESS 0 149 2,126 0 0 193.04

193.05 19305 HOME INFUSION 0 0 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 0 501,097 22,852,305 290 -33,074,388 193.06

193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 0 13,420 518,955 14 0 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 0 18,322 131 32 0 193.11

193.13 19313 HEALTHPOINT 0 63,814 1,075,645 67 0 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14

194.00 07950 JAZZMANS RESTAURANT 0 10,236 30,612 2 0 194.00





Part I)

0 15,957,953 6,957,271 656,196 202.00

203.00 Unit cost multiplier (Wkst. B, Part I) 0.000000 0.990489 0.077227 246.875847 203.00


Part II)

237,660 145,023 204.00


II)

0.002638 54.560948 205.00


MCRIF32 - 8.8.159.0 85 | Page


Date/Time Prepared:

Worksheet B-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Cost Center Description DATA

PROCESSING

(ACCUM. COST)

PURCHASING

RECEIVING AND

STORES

(SUPPLY COS

TS)

ADMITTING

(GROSS REVE

NUES)

CASHIERING/AC

COUNTS

RECEIVABLE

(GROSS REVE

NUES)

Reconciliatio

n

5.02 5.03 5.04 5.05 5A.06
















5.02 00550 DATA PROCESSING 218,149,092 5.02

5.03 00560 PURCHASING RECEIVING AND STORES 2,039,612 8,927,336 5.03

5.04 00570 ADMITTING 2,832,720 10,455 833,226,171 5.04

5.05 00580 CASHIERING/ACCOUNTS RECEIVABLE 4,241,035 9,210 0 833,226,171 5.05

5.06 00590 OTHER ADMINISTRATIVE & GENERAL 33,418,699 35,396 0 0 -35,359,578 5.06

6.00 00600 MAINTENANCE & REPAIRS 3,992,353 1,829 0 0 0 6.00

7.00 00700 OPERATION OF PLANT 5,617,039 252 0 0 0 7.00

8.00 00800 LAUNDRY & LINEN SERVICE 105,012 0 0 0 0 8.00

9.00 00900 HOUSEKEEPING 3,681,768 2,359 0 0 0 9.00

10.00 01000 DIETARY 3,144,711 978 0 0 0 10.00

11.00 01100 CAFETERIA 0 0 0 0 0 11.00


13.00 01300 NURSING ADMINISTRATION 4,616,187 19,698 0 0 0 13.00

14.00 01400 CENTRAL SERVICES & SUPPLY 1,959,419 113,737 0 0 0 14.00

15.00 01500 PHARMACY 0 0 0 0 0 15.00


17.00 01700 SOCIAL SERVICE 0 0 0 0 0 17.00


20.00 02000 NURSING SCHOOL 389,379 15,331 0 0 0 20.00

20.01 02001 SCHOOL OF MEDICAL TECHNOLOGY 43,281 125 0 0 0 20.01

20.02 02002 SCHOOL OF SURGICAL TECHNOLOGY 20,927 90 0 0 0 20.02

20.03 02003 SCHOOL OF RADIOLOGICAL TECHNOLO 50,708 138 0 0 0 20.03





30.00 03000 ADULTS & PEDIATRICS 16,156,030 527,372 30,923,210 30,923,210 0 30.00

33.01 03301 ADULT SPECIAL CARE 2,581,826 291,299 6,480,124 6,480,124 0 33.01

34.01 03401 CARDIOTHORACIC ICU 2,106,484 96,126 3,565,208 3,565,208 0 34.01

40.00 04000 SUBPROVIDER - IPF 1,269,762 2,680 2,645,527 2,645,527 0 40.00

41.00 04100 SUBPROVIDER - IRF 1,249,415 9,549 1,384,565 1,384,565 0 41.00

43.00 04300 NURSERY 831,087 27,499 2,336,657 2,336,657 0 43.00


50.00 05000 OPERATING ROOM 10,158,762 1,203,744 89,038,123 89,038,123 0 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 1,607,065 104,435 5,676,944 5,676,944 0 52.00

53.00 05300 ANESTHESIOLOGY 782,418 596,341 20,529,224 20,529,224 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 4,345,010 665,827 24,482,787 24,482,787 0 54.00

54.01 05401 ULTRASOUND 799,525 31,406 9,245,587 9,245,587 0 54.01

54.03 05403 CARDIOVASCULAR LAB 4,351,968 735,292 30,674,383 30,674,383 0 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 4,114,163 120,609 16,097,226 16,097,226 0 55.00

55.01 05501 CHEMOTHERAPY 1,254,194 66,146 4,091,450 4,091,450 0 55.01

56.01 05601 NUCLEAR MEDICINE 1,641,007 1,851 19,270,268 19,270,268 0 56.01

57.00 05700 CT SCAN 1,992,892 125,123 41,420,556 41,420,556 0 57.00

58.00 05800 MRI 1,140,048 4,663 18,091,357 18,091,357 0 58.00

60.00 06000 LABORATORY 9,590,430 10,762 75,392,079 75,392,079 0 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 909,958 4,641 5,778,105 5,778,105 0 63.00

65.00 06500 RESPIRATORY THERAPY 2,637,907 32,027 19,000,932 19,000,932 0 65.00

66.00 06600 PHYSICAL THERAPY 1,043,792 1,693 5,859,669 5,859,669 0 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 2,463,186 3,093 11,560,082 11,560,082 0 66.01

66.02 06602 PHYSIATRY 0 0 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 262,643 136 2,025,572 2,025,572 0 67.00

68.00 06800 SPEECH PATHOLOGY 191,754 0 1,637,869 1,637,869 0 68.00

69.01 06901 CV DIAGNOSTIC 1,591,554 8,876 25,275,144 25,275,144 0 69.01


70.01 07001 NEUROPHYSIOLOGY 865,006 58,568 17,135,959 17,135,959 0 70.01


MCRIF32 - 8.8.159.0 86 | Page


Date/Time Prepared:

Worksheet B-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



PROCESSING

(ACCUM. COST)

PURCHASING

RECEIVING AND

STORES

(SUPPLY COS

TS)

ADMITTING

(GROSS REVE

NUES)

CASHIERING/AC

COUNTS

RECEIVABLE

(GROSS REVE

NUES)

Reconciliatio

n

5.02 5.03 5.04 5.05 5A.06

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 11,043,821 0 87,352,621 87,352,621 0 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 16,846,024 3,076,120 76,947,713 76,947,713 0 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 19,163,280 7,422 114,961,515 114,961,515 0 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 402,670 1,075 734,782 734,782 0 76.97


76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99



88.01 08801 RURAL HEALTH CLINIC II 3,105,209 5,911 3,642,310 3,642,310 0 88.01

88.02 08802 RURAL HEALTH CLINIC III 2,567,720 21,496 3,451,296 3,451,296 0 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 604,484 4,269 4,233,724 4,233,724 0 90.01

90.02 09002 DIABETES CENTER 293,002 886 100,130 100,130 0 90.02

91.00 09100 EMERGENCY 5,776,044 475,380 39,466,693 39,466,693 0 91.00

91.01 09101 G.I. LABORATORY 1,273,087 194,746 8,529,970 8,529,970 0 91.01



101.00 10100 HOME HEALTH AGENCY 1,487,543 12,314 1,426,971 1,426,971 0 101.00



116.00 11600 HOSPICE 1,968,682 10,258 2,759,839 2,759,839 0 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 206,622,302 8,749,233 833,226,171 833,226,171 -35,359,578 118.00


190.00 19000 GIFT, FLOWER, COFFEE SHOP & CANTEEN 43,130 0 0 0 0 190.00

191.01 19101 RESPITE CARE 0 0 0 0 0 191.01





193.05 19305 HOME INFUSION 0 0 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 0 158,695 0 0 0 193.06

193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 5,370,248 2,546 0 0 0 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 2,840,234 6,858 0 0 0 193.11

193.13 19313 HEALTHPOINT 2,851,453 6,777 0 0 0 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14


194.01 07951 FOUNDATION OFFICE 89,300 1,896 0 0 0 194.01




Part I)

12,613,251 2,157,540 2,999,032 4,488,473 202.00

203.00 Unit cost multiplier (Wkst. B, Part I) 0.057819 0.241678 0.003599 0.005387 203.00


Part II)

7,691,168 351,645 303,188 345,474 204.00


II)

0.035256 0.039390 0.000364 0.000415 205.00


MCRIF32 - 8.8.159.0 87 | Page


Date/Time Prepared:

Worksheet B-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



ADMINISTRATIV

E & GENERAL

(ACCUM. COST)

MAINTENANCE &

REPAIRS

(REQUISITIO)

OPERATION OF

PLANT

(SQUARE FEET)

LAUNDRY &

LINEN SERVICE

(POUNDS OF

LAUNDRY)

HOUSEKEEPING

(SQUARE FEET)

5.06 6.00 7.00 8.00 9.00


















5.04 00570 ADMITTING 5.04


5.06 00590 OTHER ADMINISTRATIVE & GENERAL 228,477,153 5.06

6.00 00600 MAINTENANCE & REPAIRS 4,223,629 10,993 6.00

7.00 00700 OPERATION OF PLANT 5,941,872 2,190 564,155 7.00

8.00 00800 LAUNDRY & LINEN SERVICE 111,084 45 3,781 1,395,072 8.00

9.00 00900 HOUSEKEEPING 3,895,214 120 3,328 292 557,046 9.00

10.00 01000 DIETARY 3,326,771 333 12,968 0 12,968 10.00

11.00 01100 CAFETERIA 0 0 0 0 0 11.00


13.00 01300 NURSING ADMINISTRATION 4,887,851 190 13,880 0 13,880 13.00

14.00 01400 CENTRAL SERVICES & SUPPLY 2,100,199 133 3,948 0 3,948 14.00

15.00 01500 PHARMACY 0 0 0 0 0 15.00


17.00 01700 SOCIAL SERVICE 0 0 0 0 0 17.00


20.00 02000 NURSING SCHOOL 415,598 154 14,088 0 14,088 20.00

20.01 02001 SCHOOL OF MEDICAL TECHNOLOGY 45,813 0 1,011 0 1,011 20.01

20.02 02002 SCHOOL OF SURGICAL TECHNOLOGY 22,159 0 957 0 957 20.02

20.03 02003 SCHOOL OF RADIOLOGICAL TECHNOLO 53,673 0 2,193 0 2,193 20.03






33.01 03301 ADULT SPECIAL CARE 2,859,736 536 10,658 68,373 10,658 33.01

34.01 03401 CARDIOTHORACIC ICU 2,283,548 191 18,080 51,585 18,080 34.01

40.00 04000 SUBPROVIDER - IPF 1,367,598 191 5,244 73,407 5,244 40.00

41.00 04100 SUBPROVIDER - IRF 1,336,405 273 8,021 60,684 8,021 41.00

43.00 04300 NURSERY 906,784 28 1,414 0 1,414 43.00


50.00 05000 OPERATING ROOM 11,837,145 547 41,790 120,302 41,790 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 1,776,237 0 6,140 64,309 6,140 52.00

53.00 05300 ANESTHESIOLOGY 1,156,256 46 8,219 0 8,219 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 4,977,153 261 14,234 0 14,234 54.00

54.01 05401 ULTRASOUND 936,424 15 1,500 0 1,500 54.01

54.03 05403 CARDIOVASCULAR LAB 5,056,938 101 15,496 25,836 15,496 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 4,525,839 218 47,758 0 47,758 55.00

55.01 05501 CHEMOTHERAPY 1,379,462 39 21,386 0 21,386 55.01

56.01 05601 NUCLEAR MEDICINE 1,909,498 8 2,002 0 2,002 56.01

57.00 05700 CT SCAN 2,510,564 119 4,274 0 4,274 57.00

58.00 05800 MRI 1,369,660 36 4,882 0 4,882 58.00

60.00 06000 LABORATORY 10,825,013 251 14,480 0 14,480 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 1,015,615 9 330 0 330 63.00

65.00 06500 RESPIRATORY THERAPY 2,968,910 54 2,801 0 2,801 65.00

66.00 06600 PHYSICAL THERAPY 1,157,207 44 1,748 0 1,748 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 2,710,232 0 15,394 0 15,394 66.01

66.02 06602 PHYSIATRY 0 0 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 296,064 30 360 0 360 67.00


69.01 06901 CV DIAGNOSTIC 1,912,843 27 1,401 0 1,401 69.01


70.01 07001 NEUROPHYSIOLOGY 1,083,158 54 4,523 0 4,523 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 12,467,315 0 0 0 0 71.00


MCRIF32 - 8.8.159.0 88 | Page


Date/Time Prepared:

Worksheet B-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



ADMINISTRATIV

E & GENERAL

(ACCUM. COST)

MAINTENANCE &

REPAIRS

(REQUISITIO)

OPERATION OF

PLANT

(SQUARE FEET)

LAUNDRY &

LINEN SERVICE

(POUNDS OF

LAUNDRY)

HOUSEKEEPING

(SQUARE FEET)

5.06 6.00 7.00 8.00 9.00


73.00 07300 DRUGS CHARGED TO PATIENTS 21,306,255 45 4,280 0 4,280 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 432,814 47 1,470 0 1,470 76.97


76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99



88.01 08801 RURAL HEALTH CLINIC II 3,318,908 100 17,000 0 17,000 88.01

88.02 08802 RURAL HEALTH CLINIC III 2,752,391 83 11,333 0 11,333 88.02


90.02 09002 DIABETES CENTER 311,056 40 5,000 0 5,000 90.02

91.00 09100 EMERGENCY 6,579,546 543 12,203 1,971 12,203 91.00

91.01 09101 G.I. LABORATORY 1,470,412 119 8,278 9,086 8,278 91.01



101.00 10100 HOME HEALTH AGENCY 1,589,350 41 3,286 0 3,286 101.00



116.00 11600 HOSPICE 2,109,788 61 3,286 0 3,286 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 183,166,465 9,708 457,435 1,395,072 450,326 118.00


190.00 19000 GIFT, FLOWER, COFFEE SHOP & CANTEEN 45,624 38 2,256 0 2,256 190.00

191.01 19101 RESPITE CARE 0 0 0 0 0 191.01



193.03 19303 LACEYS RESTAURANT 90,110 137 3,900 0 3,900 193.03


193.05 19305 HOME INFUSION 0 0 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 33,112,741 903 34,977 0 34,977 193.06

193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 5,681,365 19 1,950 0 1,950 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 3,006,110 106 5,615 0 5,615 193.11

193.13 19313 HEALTHPOINT 3,017,959 36 52,510 0 52,510 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14


194.01 07951 FOUNDATION OFFICE 94,921 35 5,005 0 5,005 194.01




Part I)

35,359,578 4,877,286 7,833,090 200,739 4,597,536 202.00



Part II)

1,897,879 657,766 2,750,497 100,244 325,309 204.00


II)

0.008307 59.834986 4.875428 0.071856 0.583989 205.00


MCRIF32 - 8.8.159.0 89 | Page


Date/Time Prepared:

Worksheet B-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Cost Center Description DIETARY

(MEALS

SERVED)

CAFETERIA

(MEALS

SERVED)

MAINTENANCE

OF PERSONNEL

(NUMBER

HOUSED)

NURSING

ADMINISTRATIO

N

(FTES SERV

ICE)

CENTRAL

SERVICES &

SUPPLY

(SUPPLY COS

TS)

10.00 11.00 12.00 13.00 14.00


















5.04 00570 ADMITTING 5.04







10.00 01000 DIETARY 240,527 10.00

11.00 01100 CAFETERIA 125,223 125,223 11.00

12.00 01200 MAINTENANCE OF PERSONNEL 0 0 0 12.00

13.00 01300 NURSING ADMINISTRATION 0 4,583 0 399 13.00

14.00 01400 CENTRAL SERVICES & SUPPLY 0 2,186 0 0 36,038,998 14.00

15.00 01500 PHARMACY 0 0 0 0 0 15.00


17.00 01700 SOCIAL SERVICE 0 0 0 0 0 17.00


20.00 02000 NURSING SCHOOL 0 2,560 0 0 0 20.00








30.00 03000 ADULTS & PEDIATRICS 89,915 23,722 0 251 800,038 30.00

33.01 03301 ADULT SPECIAL CARE 3,895 2,881 0 30 384,706 33.01

34.01 03401 CARDIOTHORACIC ICU 3,990 2,163 0 23 151,185 34.01

40.00 04000 SUBPROVIDER - IPF 9,567 1,820 0 19 6,534 40.00

41.00 04100 SUBPROVIDER - IRF 7,047 1,528 0 16 20,214 41.00

43.00 04300 NURSERY 0 835 0 9 28,439 43.00


50.00 05000 OPERATING ROOM 297 7,093 0 0 7,502,058 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0 1,872 0 0 124,521 52.00

53.00 05300 ANESTHESIOLOGY 0 2,436 0 0 694,180 53.00


54.01 05401 ULTRASOUND 0 664 0 0 41,965 54.01

54.03 05403 CARDIOVASCULAR LAB 41 2,038 0 0 3,528,463 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0 1,744 0 0 121,272 55.00

55.01 05501 CHEMOTHERAPY 0 1,200 0 0 89,037 55.01

56.01 05601 NUCLEAR MEDICINE 93 430 0 0 2,790 56.01

57.00 05700 CT SCAN 0 841 0 0 152,839 57.00

58.00 05800 MRI 0 446 0 0 12,648 58.00

60.00 06000 LABORATORY 0 8,544 0 0 2,593,768 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0 1 0 0 135,027 63.00

65.00 06500 RESPIRATORY THERAPY 0 2,790 0 0 341,008 65.00

66.00 06600 PHYSICAL THERAPY 0 1,199 0 0 2,097 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0 3,158 0 0 15,049 66.01

66.02 06602 PHYSIATRY 0 0 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 0 329 0 0 1,735 67.00


69.01 06901 CV DIAGNOSTIC 0 1,301 0 0 21,135 69.01


70.01 07001 NEUROPHYSIOLOGY 12 887 0 0 91,200 70.01


MCRIF32 - 8.8.159.0 90 | Page


Date/Time Prepared:

Worksheet B-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



(MEALS

SERVED)

CAFETERIA

(MEALS

SERVED)

MAINTENANCE

OF PERSONNEL

(NUMBER

HOUSED)

NURSING

ADMINISTRATIO

N

(FTES SERV

ICE)

CENTRAL

SERVICES &

SUPPLY

(SUPPLY COS

TS)

10.00 11.00 12.00 13.00 14.00


72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0 0 0 0 17,281,416 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 0 2,873 0 0 0 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 0 592 0 6 1,610 76.97


76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99



88.01 08801 RURAL HEALTH CLINIC II 0 2,342 0 0 18,083 88.01

88.02 08802 RURAL HEALTH CLINIC III 0 1,405 0 0 39,501 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 0 727 0 0 36,281 90.01

90.02 09002 DIABETES CENTER 0 275 0 3 331 90.02

91.00 09100 EMERGENCY 447 7,567 0 0 571,124 91.00

91.01 09101 G.I. LABORATORY 0 798 0 0 228,584 91.01






116.00 11600 HOSPICE 0 0 0 18 14,787 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 240,527 100,822 0 390 35,820,464 118.00



191.01 19101 RESPITE CARE 0 0 0 0 0 191.01





193.05 19305 HOME INFUSION 0 0 0 0 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 0 19,390 0 1 218,534 193.06

193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 0 659 0 0 0 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 0 1,146 0 0 0 193.11

193.13 19313 HEALTHPOINT 0 3,076 0 8 0 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14






Part I)

4,276,458 2,226,408 0 6,117,364 2,610,506 202.00

203.00 Unit cost multiplier (Wkst. B, Part I) 17.779534 17.779545 0.000000 15,331.739348 0.072436 203.00


Part II)

564,448 293,864 0 772,153 583,482 204.00


II)

2.346714 2.346725 0.000000 1,935.220551 0.016190 205.00


MCRIF32 - 8.8.159.0 91 | Page


Date/Time Prepared:

Worksheet B-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Cost Center Description PHARMACY

(COSTED

REQUIS.)

MEDICAL

RECORDS &

LIBRARY

(TIME SPENT)

SOCIAL

SERVICE

(TIME SPENT)

NONPHYSICIAN

ANESTHETISTS

(ASSIGNED

TIME)

NURSING

SCHOOL

(ASSIGNED

TIME)

15.00 16.00 17.00 19.00 20.00


















5.04 00570 ADMITTING 5.04







10.00 01000 DIETARY 10.00

11.00 01100 CAFETERIA 11.00




15.00 01500 PHARMACY 0 15.00


17.00 01700 SOCIAL SERVICE 0 0 0 17.00

19.00 01900 NONPHYSICIAN ANESTHETISTS 0 0 0 0 19.00

20.00 02000 NURSING SCHOOL 0 0 0 19,128 20.00

20.01 02001 SCHOOL OF MEDICAL TECHNOLOGY 0 0 0 20.01

20.02 02002 SCHOOL OF SURGICAL TECHNOLOGY 0 0 0 20.02

20.03 02003 SCHOOL OF RADIOLOGICAL TECHNOLO 0 0 0 20.03

21.00 02100 I&R SERVICES-SALARY & FRINGES APPRV 0 0 0 21.00

22.00 02200 I&R SERVICES-OTHER PRGM COSTS APPRV 0 0 0 22.00

23.00 02300 PARAMEDICAL EDUCATION PROGRAM 0 0 0 23.00


30.00 03000 ADULTS & PEDIATRICS 0 0 0 0 13,953 30.00



40.00 04000 SUBPROVIDER - IPF 0 0 0 0 1,408 40.00

41.00 04100 SUBPROVIDER - IRF 0 0 0 0 1,045 41.00

43.00 04300 NURSERY 0 0 0 0 0 43.00


50.00 05000 OPERATING ROOM 0 0 0 0 181 50.00


53.00 05300 ANESTHESIOLOGY 0 0 0 0 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0 0 0 0 0 54.00

54.01 05401 ULTRASOUND 0 0 0 0 0 54.01



55.01 05501 CHEMOTHERAPY 0 0 0 0 0 55.01


57.00 05700 CT SCAN 0 0 0 0 0 57.00

58.00 05800 MRI 0 0 0 0 0 58.00

60.00 06000 LABORATORY 0 0 0 0 0 60.00






66.02 06602 PHYSIATRY 0 0 0 0 0 66.02



69.01 06901 CV DIAGNOSTIC 0 0 0 0 0 69.01





MCRIF32 - 8.8.159.0 92 | Page


Date/Time Prepared:

Worksheet B-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



(COSTED

REQUIS.)

MEDICAL

RECORDS &

LIBRARY

(TIME SPENT)

SOCIAL

SERVICE

(TIME SPENT)

NONPHYSICIAN

ANESTHETISTS

(ASSIGNED

TIME)

NURSING

SCHOOL

(ASSIGNED

TIME)

15.00 16.00 17.00 19.00 20.00



76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00



76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99






90.02 09002 DIABETES CENTER 0 0 0 0 0 90.02

91.00 09100 EMERGENCY 0 0 0 0 965 91.00

91.01 09101 G.I. LABORATORY 0 0 0 0 0 91.01






116.00 11600 HOSPICE 0 0 0 0 528 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 0 0 0 0 19,128 118.00



191.01 19101 RESPITE CARE 0 0 0 0 0 191.01





193.05 19305 HOME INFUSION 0 0 0 0 0 193.05


193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 0 0 0 0 0 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 0 0 0 0 0 193.11

193.13 19313 HEALTHPOINT 0 0 0 0 0 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14






Part I)

0 0 0 0 905,639 202.00



Part II)

0 0 0 0 370,850 204.00


II)

0.000000 0.000000 0.000000 0.000000 19.387808 205.00


MCRIF32 - 8.8.159.0 93 | Page


Date/Time Prepared:

Worksheet B-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


INTERNS & RESIDENTS


MEDICAL

TECHNOLOGY

(TIME SPENT)

SCHOOL OF

SURGICAL

TECHNOLOGY

(TIME SPENT)

SCHOOL OF

RADIOLOGICAL

TECHNOLO

(TIME SPENT)

SERVICES-SALA

RY & FRINGES

APPRV

(ASSIGNED

TIME)

SERVICES-OTHE

R PRGM COSTS

APPRV

(ASSIGNED

TIME)

20.01 20.02 20.03 21.00 22.00


















5.04 00570 ADMITTING 5.04







10.00 01000 DIETARY 10.00

11.00 01100 CAFETERIA 11.00




15.00 01500 PHARMACY 15.00












30.00 03000 ADULTS & PEDIATRICS 0 0 0 0 0 30.00



40.00 04000 SUBPROVIDER - IPF 0 0 0 0 0 40.00

41.00 04100 SUBPROVIDER - IRF 0 0 0 0 0 41.00

43.00 04300 NURSERY 0 0 0 0 0 43.00


50.00 05000 OPERATING ROOM 0 1,200 0 0 0 50.00


53.00 05300 ANESTHESIOLOGY 0 0 0 0 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0 0 1,883 0 0 54.00

54.01 05401 ULTRASOUND 0 0 0 0 0 54.01



55.01 05501 CHEMOTHERAPY 0 0 0 0 0 55.01


57.00 05700 CT SCAN 0 0 0 0 0 57.00

58.00 05800 MRI 0 0 0 0 0 58.00

60.00 06000 LABORATORY 2,520 0 0 0 0 60.00






66.02 06602 PHYSIATRY 0 0 0 0 0 66.02



69.01 06901 CV DIAGNOSTIC 0 0 0 0 0 69.01


MCRIF32 - 8.8.159.0 94 | Page


Date/Time Prepared:

Worksheet B-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


INTERNS & RESIDENTS


MEDICAL

TECHNOLOGY

(TIME SPENT)

SCHOOL OF

SURGICAL

TECHNOLOGY

(TIME SPENT)

SCHOOL OF

RADIOLOGICAL

TECHNOLO

(TIME SPENT)

SERVICES-SALA

RY & FRINGES

APPRV

(ASSIGNED

TIME)

SERVICES-OTHE

R PRGM COSTS

APPRV

(ASSIGNED

TIME)

20.01 20.02 20.03 21.00 22.00






76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00



76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99






90.02 09002 DIABETES CENTER 0 0 0 0 0 90.02

91.00 09100 EMERGENCY 0 0 0 0 0 91.00

91.01 09101 G.I. LABORATORY 0 0 0 0 0 91.01






116.00 11600 HOSPICE 0 0 0 0 0 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 2,520 1,200 1,883 0 0 118.00



191.01 19101 RESPITE CARE 0 0 0 0 0 191.01





193.05 19305 HOME INFUSION 0 0 0 0 0 193.05


193.07 19307 GENERATIONS 0 0 0 0 0 193.07

193.08 19308 RETAIL PHARMACY 0 0 0 0 0 193.08

193.09 19309 OUTREACH LAB 0 0 0 0 0 193.09

193.10 19310 FOOT CLINIC 0 0 0 0 0 193.10

193.11 19311 MARKETING 0 0 0 0 0 193.11

193.13 19313 HEALTHPOINT 0 0 0 0 0 193.13

193.14 19314 DOCTORS PARK 0 0 0 0 0 193.14






Part I)

78,644 48,464 113,889 0 0 202.00



Part II)

26,879 23,654 53,715 0 0 204.00


II)

10.666270 19.711667 28.526288 0.000000 0.000000 205.00


MCRIF32 - 8.8.159.0 95 | Page


Date/Time Prepared:

Worksheet B-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



EDUCATION

PROGRAM

(ASSIGNED

TIME)

23.00


















5.04 00570 ADMITTING 5.04







10.00 01000 DIETARY 10.00

11.00 01100 CAFETERIA 11.00




15.00 01500 PHARMACY 15.00












30.00 03000 ADULTS & PEDIATRICS 0 30.00

33.01 03301 ADULT SPECIAL CARE 0 33.01

34.01 03401 CARDIOTHORACIC ICU 0 34.01

40.00 04000 SUBPROVIDER - IPF 0 40.00

41.00 04100 SUBPROVIDER - IRF 0 41.00

43.00 04300 NURSERY 0 43.00


50.00 05000 OPERATING ROOM 0 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0 52.00

53.00 05300 ANESTHESIOLOGY 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0 54.00

54.01 05401 ULTRASOUND 0 54.01

54.03 05403 CARDIOVASCULAR LAB 0 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0 55.00

55.01 05501 CHEMOTHERAPY 0 55.01

56.01 05601 NUCLEAR MEDICINE 0 56.01

57.00 05700 CT SCAN 0 57.00

58.00 05800 MRI 0 58.00

60.00 06000 LABORATORY 0 60.00

62.30 06250 BLOOD CLOTTING FACTORS FOR HEMOPH. 0 62.30

63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0 63.00

65.00 06500 RESPIRATORY THERAPY 0 65.00

66.00 06600 PHYSICAL THERAPY 0 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0 66.01

66.02 06602 PHYSIATRY 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 0 67.00

68.00 06800 SPEECH PATHOLOGY 0 68.00

69.01 06901 CV DIAGNOSTIC 0 69.01

69.02 06902 ELECTROPHYSIOLOGY LAB 0 69.02

70.01 07001 NEUROPHYSIOLOGY 0 70.01


MCRIF32 - 8.8.159.0 96 | Page


Date/Time Prepared:

Worksheet B-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



EDUCATION

PROGRAM

(ASSIGNED

TIME)

23.00

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 0 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 0 73.00

76.00 03950 CARDIAC REHAB 0 76.00

76.97 07697 CARDIAC REHABILITATION 0 76.97

76.98 07698 HYPERBARIC OXYGEN THERAPY 0 76.98

76.99 07699 LITHOTRIPSY 0 76.99


88.00 08800 RURAL HEALTH CLINIC 0 88.00

88.01 08801 RURAL HEALTH CLINIC II 0 88.01

88.02 08802 RURAL HEALTH CLINIC III 0 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 0 90.01

90.02 09002 DIABETES CENTER 0 90.02

91.00 09100 EMERGENCY 0 91.00

91.01 09101 G.I. LABORATORY 0 91.01



101.00 10100 HOME HEALTH AGENCY 0 101.00



116.00 11600 HOSPICE 0 116.00

118.00 SUBTOTALS (SUM OF LINES 1-117) 0 118.00


190.00 19000 GIFT, FLOWER, COFFEE SHOP & CANTEEN 0 190.00

191.01 19101 RESPITE CARE 0 191.01

193.01 19301 VENDING MACHINES 0 193.01

193.02 19302 SUNSET GUEST HOUSE 0 193.02

193.03 19303 LACEYS RESTAURANT 0 193.03

193.04 19304 COMMUNITY WELLNESS 0 193.04

193.05 19305 HOME INFUSION 0 193.05

193.06 19306 SE HOSP PHYSICIANS LLC 0 193.06

193.07 19307 GENERATIONS 0 193.07

193.08 19308 RETAIL PHARMACY 0 193.08

193.09 19309 OUTREACH LAB 0 193.09

193.10 19310 FOOT CLINIC 0 193.10

193.11 19311 MARKETING 0 193.11

193.13 19313 HEALTHPOINT 0 193.13

193.14 19314 DOCTORS PARK 0 193.14

194.00 07950 JAZZMANS RESTAURANT 0 194.00

194.01 07951 FOUNDATION OFFICE 0 194.01




Part I)

0 202.00

203.00 Unit cost multiplier (Wkst. B, Part I) 0.000000 203.00


Part II)

0 204.00


II)

0.000000 205.00


MCRIF32 - 8.8.159.0 97 | Page


Date/Time Prepared:

Worksheet C

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110COMPUTATION OF RATIO OF COSTS TO CHARGES

Title XVIII Hospital PPS

Costs

Cost Center Description Total Cost

(from Wkst.

B, Part I,

col. 26)

Therapy Limit

Adj.

Total Costs RCE

Disallowance

Total Costs

1.00 2.00 3.00 4.00 5.00


30.00 03000 ADULTS & PEDIATRICS 29,782,995 29,782,995 0 29,782,995 30.00

33.01 03301 ADULT SPECIAL CARE 4,394,201 4,394,201 0 4,394,201 33.01

34.01 03401 CARDIOTHORACIC ICU 3,631,943 3,631,943 0 3,631,943 34.01

40.00 04000 SUBPROVIDER - IPF 2,351,542 2,351,542 0 2,351,542 40.00

41.00 04100 SUBPROVIDER - IRF 2,299,362 2,299,362 0 2,299,362 41.00

43.00 04300 NURSERY 1,245,738 1,245,738 0 1,245,738 43.00


50.00 05000 OPERATING ROOM 15,586,078 15,586,078 0 15,586,078 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 2,238,615 2,238,615 0 2,238,615 52.00

53.00 05300 ANESTHESIOLOGY 1,631,157 1,631,157 0 1,631,157 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 6,423,518 6,423,518 0 6,423,518 54.00

54.01 05401 ULTRASOUND 1,136,055 1,136,055 0 1,136,055 54.01

54.03 05403 CARDIOVASCULAR LAB 6,530,084 6,530,084 0 6,530,084 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 6,420,049 6,420,049 0 6,420,049 55.00

55.01 05501 CHEMOTHERAPY 2,111,482 2,111,482 0 2,111,482 55.01

56.01 05601 NUCLEAR MEDICINE 2,262,385 2,262,385 0 2,262,385 56.01

57.00 05700 CT SCAN 3,072,543 3,072,543 0 3,072,543 57.00

58.00 05800 MRI 1,714,527 1,714,527 0 1,714,527 58.00

60.00 06000 LABORATORY 13,350,670 13,350,670 0 13,350,670 60.00

62.30 06250 BLOOD CLOTTING FACTORS FOR HEMOPH. 0 0 0 0 62.30

63.00 06300 BLOOD STORING, PROCESSING & TRANS. 1,193,892 1,193,892 0 1,193,892 63.00

65.00 06500 RESPIRATORY THERAPY 3,588,657 0 3,588,657 0 3,588,657 65.00

66.00 06600 PHYSICAL THERAPY 1,415,988 0 1,415,988 0 1,415,988 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 3,527,704 0 3,527,704 0 3,527,704 66.01

66.02 06602 PHYSIATRY 0 0 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 369,137 0 369,137 0 369,137 67.00

68.00 06800 SPEECH PATHOLOGY 258,428 0 258,428 0 258,428 68.00

69.01 06901 CV DIAGNOSTIC 2,276,534 2,276,534 0 2,276,534 69.01

69.02 06902 ELECTROPHYSIOLOGY LAB 0 0 0 0 69.02

70.01 07001 NEUROPHYSIOLOGY 1,397,467 1,397,467 0 1,397,467 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 14,396,782 14,396,782 0 14,396,782 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 23,486,633 23,486,633 0 23,486,633 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 24,769,451 24,769,451 0 24,769,451 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 655,825 655,825 0 655,825 76.97

76.98 07698 HYPERBARIC OXYGEN THERAPY 0 0 0 0 76.98

76.99 07699 LITHOTRIPSY 0 0 0 0 76.99


88.00 08800 RURAL HEALTH CLINIC 0 0 0 0 88.00

88.01 08801 RURAL HEALTH CLINIC II 4,296,213 4,296,213 0 4,296,213 88.01

88.02 08802 RURAL HEALTH CLINIC III 3,493,914 3,493,914 0 3,493,914 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 831,017 831,017 0 831,017 90.01

90.02 09002 DIABETES CENTER 538,541 538,541 0 538,541 90.02

91.00 09100 EMERGENCY 8,338,703 8,338,703 0 8,338,703 91.00

91.01 09101 G.I. LABORATORY 1,966,085 1,966,085 0 1,966,085 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 4,156,125 4,156,125 4,156,125 92.00


101.00 10100 HOME HEALTH AGENCY 2,171,258 2,171,258 2,171,258 101.00



116.00 11600 HOSPICE 2,838,154 2,838,154 2,838,154 116.00

200.00 Subtotal (see instructions) 212,149,452 0 212,149,452 0 212,149,452 200.00

201.00 Less Observation Beds 4,156,125 4,156,125 4,156,125 201.00

202.00 Total (see instructions) 207,993,327 0 207,993,327 0 207,993,327 202.00


MCRIF32 - 8.8.159.0 98 | Page


Date/Time Prepared:

Worksheet C

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



Charges

Cost Center Description Inpatient Outpatient Total (col. 6

+ col. 7)

Cost or Other

Ratio

TEFRA

Inpatient

Ratio

6.00 7.00 8.00 9.00 10.00


30.00 03000 ADULTS & PEDIATRICS 20,751,278 20,751,278 30.00

33.01 03301 ADULT SPECIAL CARE 6,480,124 6,480,124 33.01

34.01 03401 CARDIOTHORACIC ICU 3,565,208 3,565,208 34.01

40.00 04000 SUBPROVIDER - IPF 2,645,527 2,645,527 40.00

41.00 04100 SUBPROVIDER - IRF 1,384,565 1,384,565 41.00

43.00 04300 NURSERY 2,336,657 2,336,657 43.00


50.00 05000 OPERATING ROOM 45,580,171 43,457,952 89,038,123 0.175049 0.000000 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 4,925,537 751,407 5,676,944 0.394335 0.000000 52.00

53.00 05300 ANESTHESIOLOGY 11,009,625 9,519,599 20,529,224 0.079455 0.000000 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 8,442,901 16,039,886 24,482,787 0.262369 0.000000 54.00

54.01 05401 ULTRASOUND 2,413,498 6,832,089 9,245,587 0.122875 0.000000 54.01

54.03 05403 CARDIOVASCULAR LAB 11,769,736 18,904,647 30,674,383 0.212884 0.000000 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 663,060 15,434,166 16,097,226 0.398830 0.000000 55.00

55.01 05501 CHEMOTHERAPY 13,594 4,077,856 4,091,450 0.516072 0.000000 55.01

56.01 05601 NUCLEAR MEDICINE 1,617,282 17,652,986 19,270,268 0.117403 0.000000 56.01

57.00 05700 CT SCAN 9,650,409 31,770,147 41,420,556 0.074179 0.000000 57.00

58.00 05800 MRI 2,925,525 15,165,832 18,091,357 0.094771 0.000000 58.00

60.00 06000 LABORATORY 34,510,887 40,881,192 75,392,079 0.177083 0.000000 60.00

62.30 06250 BLOOD CLOTTING FACTORS FOR HEMOPH. 0 0 0 0.000000 0.000000 62.30

63.00 06300 BLOOD STORING, PROCESSING & TRANS. 5,449,221 328,884 5,778,105 0.206623 0.000000 63.00

65.00 06500 RESPIRATORY THERAPY 15,378,964 3,621,968 19,000,932 0.188867 0.000000 65.00

66.00 06600 PHYSICAL THERAPY 5,646,346 213,323 5,859,669 0.241650 0.000000 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0 11,560,082 11,560,082 0.305163 0.000000 66.01

66.02 06602 PHYSIATRY 0 0 0 0.000000 0.000000 66.02

67.00 06700 OCCUPATIONAL THERAPY 1,982,677 42,895 2,025,572 0.182238 0.000000 67.00

68.00 06800 SPEECH PATHOLOGY 1,530,995 106,874 1,637,869 0.157783 0.000000 68.00

69.01 06901 CV DIAGNOSTIC 6,884,569 18,390,575 25,275,144 0.090070 0.000000 69.01

69.02 06902 ELECTROPHYSIOLOGY LAB 0 0 0 0.000000 0.000000 69.02

70.01 07001 NEUROPHYSIOLOGY 9,242,230 7,893,729 17,135,959 0.081552 0.000000 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 48,144,602 39,208,019 87,352,621 0.164812 0.000000 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 51,471,593 25,476,120 76,947,713 0.305228 0.000000 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 50,636,568 64,324,947 114,961,515 0.215459 0.000000 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0.000000 0.000000 76.00

76.97 07697 CARDIAC REHABILITATION 9,503 725,279 734,782 0.892544 0.000000 76.97

76.98 07698 HYPERBARIC OXYGEN THERAPY 0 0 0 0.000000 0.000000 76.98

76.99 07699 LITHOTRIPSY 0 0 0 0.000000 0.000000 76.99



88.01 08801 RURAL HEALTH CLINIC II 0 3,642,310 3,642,310 88.01

88.02 08802 RURAL HEALTH CLINIC III 0 3,451,296 3,451,296 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 33,150 4,200,574 4,233,724 0.196285 0.000000 90.01

90.02 09002 DIABETES CENTER 231 99,899 100,130 5.378418 0.000000 90.02

91.00 09100 EMERGENCY 7,919,394 31,547,299 39,466,693 0.211285 0.000000 91.00

91.01 09101 G.I. LABORATORY 1,882,726 6,647,244 8,529,970 0.230491 0.000000 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 2,756,062 7,415,870 10,171,932 0.408588 0.000000 92.00


101.00 10100 HOME HEALTH AGENCY 0 1,426,971 1,426,971 101.00



116.00 11600 HOSPICE 0 2,759,839 2,759,839 116.00

200.00 Subtotal (see instructions) 379,654,415 453,571,756 833,226,171 200.00

201.00 Less Observation Beds 201.00

202.00 Total (see instructions) 379,654,415 453,571,756 833,226,171 202.00


MCRIF32 - 8.8.159.0 99 | Page


Date/Time Prepared:

Worksheet C

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



Cost Center Description PPS Inpatient

Ratio

11.00







43.00 04300 NURSERY 43.00


50.00 05000 OPERATING ROOM 0.175049 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0.394335 52.00

53.00 05300 ANESTHESIOLOGY 0.079455 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0.262369 54.00

54.01 05401 ULTRASOUND 0.122875 54.01

54.03 05403 CARDIOVASCULAR LAB 0.212884 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0.398830 55.00

55.01 05501 CHEMOTHERAPY 0.516072 55.01

56.01 05601 NUCLEAR MEDICINE 0.117403 56.01

57.00 05700 CT SCAN 0.074179 57.00

58.00 05800 MRI 0.094771 58.00

60.00 06000 LABORATORY 0.177083 60.00

62.30 06250 BLOOD CLOTTING FACTORS FOR HEMOPH. 0.000000 62.30

63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0.206623 63.00

65.00 06500 RESPIRATORY THERAPY 0.188867 65.00

66.00 06600 PHYSICAL THERAPY 0.241650 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0.305163 66.01

66.02 06602 PHYSIATRY 0.000000 66.02

67.00 06700 OCCUPATIONAL THERAPY 0.182238 67.00

68.00 06800 SPEECH PATHOLOGY 0.157783 68.00

69.01 06901 CV DIAGNOSTIC 0.090070 69.01

69.02 06902 ELECTROPHYSIOLOGY LAB 0.000000 69.02

70.01 07001 NEUROPHYSIOLOGY 0.081552 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 0.164812 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0.305228 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 0.215459 73.00

76.00 03950 CARDIAC REHAB 0.000000 76.00

76.97 07697 CARDIAC REHABILITATION 0.892544 76.97

76.98 07698 HYPERBARIC OXYGEN THERAPY 0.000000 76.98

76.99 07699 LITHOTRIPSY 0.000000 76.99


88.00 08800 RURAL HEALTH CLINIC 88.00

88.01 08801 RURAL HEALTH CLINIC II 88.01

88.02 08802 RURAL HEALTH CLINIC III 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 0.196285 90.01

90.02 09002 DIABETES CENTER 5.378418 90.02

91.00 09100 EMERGENCY 0.211285 91.00

91.01 09101 G.I. LABORATORY 0.230491 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 0.408588 92.00





116.00 11600 HOSPICE 116.00

200.00 Subtotal (see instructions) 200.00


202.00 Total (see instructions) 202.00


MCRIF32 - 8.8.159.0 100 | Page

Client Name: Southeast HealthEngagement: CR2015Period Ending: 12/31/15Workpaper: C.01 - Patient Revenue Summary

Purpose: To summarize the inpatient and outpatient revenues to be reported on Worksheet C.

A B C D E F G H I J

Adjusted Adjusted AdjustedCMS Inpatient Outpatient Total Inpatient Outpatient Inpatient Outpatient Inpatient Outpatient TotalLine CMS Description Revenue Revenue Revenue Amount Amount Amount Amount Revenue Revenue Revenue

G.6 G.6 crossfoot C.02 C.02 C.03 C.03 A+D+F B+E+G H+I

30 ADULTS & PEDIATRICS 38,714,797 15,840,572 54,555,369 (12,976,133) (15,827,320) (4,987,386) (13,252) 20,751,278 - 20,751,278 33.01 ADULT SPECIAL CARE 6,781,391 133,572 6,914,963 (251,535) (133,572) (49,732) - 6,480,124 - 6,480,124 34.01 CARDIOTHORACIC ICU 3,998,566 79,125 4,077,691 (408,035) (79,125) (25,323) - 3,565,208 - 3,565,208

40 SUBPROVIDER - IPF 3,381,778 84,462 3,466,240 (5,772) 5,772 (730,479) (90,234) 2,645,527 - 2,645,527 41 SUBPROVIDER - IRF 1,449,679 - 1,449,679 - - (65,114) - 1,384,565 - 1,384,565 43 NURSERY 2,464,617 3,980 2,468,597 (1,124) (3,980) (126,836) - 2,336,657 - 2,336,657

placeholder - - - - - - - - - - 50 OPERATING ROOM 116,495,189 78,252,157 194,747,346 (70,346,837) (33,109,838) (568,181) (1,684,367) 45,580,171 43,457,952 89,038,123 52 DELIVERY ROOM & LABOR ROOM - - - 5,239,001 769,643 (313,464) (18,236) 4,925,537 751,407 5,676,944 53 ANESTHESIOLOGY 15,006,237 35,943,753 50,949,990 (3,804,149) (4,022,592) (192,463) (22,401,562) 11,009,625 9,519,599 20,529,224 54 RADIOLOGY-DIAGNOSTIC 10,091,477 18,423,834 28,515,311 (1,568,213) (1,790,283) (80,363) (593,665) 8,442,901 16,039,886 24,482,787

54.01 ULTRASOUND 2,523,456 7,360,482 9,883,938 (67,415) (100,442) (42,543) (427,951) 2,413,498 6,832,089 9,245,587 54.03 CARDIOVASCULAR LAB 24,043,423 42,498,094 66,541,517 (12,212,179) (23,193,206) (61,508) (400,241) 11,769,736 18,904,647 30,674,383

55 RADIOLOGY-THERAPEUTIC 665,349 16,095,509 16,760,858 - (8,300) (2,289) (653,043) 663,060 15,434,166 16,097,226 55.01 CHEMOTHERAPY 29,014 7,133,197 7,162,211 (15,420) (2,876,395) - (178,946) 13,594 4,077,856 4,091,450 56.01 NUCLEAR MEDICINE 1,658,463 18,140,489 19,798,952 (397) (5,512) (40,784) (481,991) 1,617,282 17,652,986 19,270,268

57 CT SCAN 10,334,474 34,300,866 44,635,340 (512,201) (1,651,037) (171,864) (879,682) 9,650,409 31,770,147 41,420,556 58 MRI 2,989,188 15,942,292 18,931,480 (24,420) (69,758) (39,243) (706,702) 2,925,525 15,165,832 18,091,357 60 LABORATORY 34,991,981 42,289,587 77,281,568 - - (481,094) (1,408,395) 34,510,887 40,881,192 75,392,079

62.3 BLOOD CLOTTING FOR HEMOPHILIACS - - - - - - - - - - 63 BLOOD STORING, PROCESSING & TRANS. 5,530,552 362,765 5,893,317 - - (81,331) (33,881) 5,449,221 328,884 5,778,105 65 RESPIRATORY THERAPY 25,614,689 4,920,908 30,535,597 (10,088,825) (1,199,526) (146,900) (99,414) 15,378,964 3,621,968 19,000,932 66 PHYSICAL THERAPY 5,729,973 214,446 5,944,419 - - (83,627) (1,123) 5,646,346 213,323 5,859,669

66.01 SOUTHEAST OUTPATIENT REHAB - 12,165,350 12,165,350 - - - (605,268) - 11,560,082 11,560,082 66.02 PHYSIATRY - - - - - - - - - -

67 OCCUPATIONAL THERAPY 2,033,298 43,189 2,076,487 - - (50,621) (294) 1,982,677 42,895 2,025,572 68 SPEECH PATHOLOGY 1,582,840 107,712 1,690,552 - - (51,845) (838) 1,530,995 106,874 1,637,869

69.01 CV DIAGNOSTIC 7,155,707 19,032,284 26,187,991 - - (271,138) (641,709) 6,884,569 18,390,575 25,275,144 69.02 ELECTROPHYSIOLOGY LAB - - - - - - - - - - 70.01 NEUROPHYSIOLOGY 9,749,088 8,357,713 18,106,801 (356,868) (137,870) (149,990) (326,114) 9,242,230 7,893,729 17,135,959

71 MEDICAL SUPPLIES CHARGED TO PATIENT - - - 48,701,232 40,474,547 (556,630) (1,266,528) 48,144,602 39,208,019 87,352,621 72 IMPL. DEV. CHARGED TO PATIENTS - - - 52,111,441 26,028,326 (639,848) (552,206) 51,471,593 25,476,120 76,947,713 73 DRUGS CHARGED TO PATIENTS 46,590,983 55,129,981 101,720,964 4,940,579 11,537,292 (894,994) (2,342,326) 50,636,568 64,324,947 114,961,515 76 NOT USED - - - - - - - - - -

76.97 CARDIAC REHABILITATION 9,503 753,043 762,546 - - - (27,764) 9,503 725,279 734,782 76.98 HYPERBARIC OXYGEN THERAPY - - - - - - - - - - 76.99 LITHOTRIPSY - - - - - - - - - -

placeholder - - - - - - - - - - 88 RURAL HEALTH CLINIC - - - - - - - - - -

88.01 RURAL HEALTH CLINIC II - 3,642,310 3,642,310 - - - - - 3,642,310 3,642,310 88.02 RURAL HEALTH CLINIC III - 3,468,747 3,468,747 - - - (17,451) - 3,451,296 3,451,296 90.01 HYPERBARIC WOUND CLINIC 33,150 4,954,844 4,987,994 - - - (754,270) 33,150 4,200,574 4,233,724 90.02 DIABETES CENTER 231 107,212 107,443 - - - (7,313) 231 99,899 100,130

91 EMERGENCY 8,253,655 47,220,455 55,474,110 (208,718) (1,161,802) (125,543) (14,511,354) 7,919,394 31,547,299 39,466,693 91.01 G.I. LABORATORY 1,932,777 7,245,712 9,178,489 (12,081) (48,726) (37,970) (549,742) 1,882,726 6,647,244 8,529,970

92 OBSERVATION BEDS (NON-DISTINCT PART 561,896 1,402,082 1,963,978 2,269,604 6,202,169 (75,438) (188,381) 2,756,062 7,415,870 10,171,932 placeholder - - - - - - - - - -

101 HOME HEALTH AGENCY - 1,426,971 1,426,971 - - - - - 1,426,971 1,426,971 placeholder - - - - - - - - - -

113 INTEREST EXPENSE - - - - - - - - - - 116 HOSPICE - 2,759,839 2,759,839 - - - - - 2,759,839 2,759,839 118 Total W/S C Charges 390,397,421 505,837,534 896,234,955 401,535 (401,535) (11,144,541) (51,864,243) 379,654,415 453,571,756 833,226,171

Reclassifications Adjustments

Client Name: Southeast HealthEngagement: CR2015Period Ending: 12/31/15Workpaper: C.01 - Patient Revenue Summary

Purpose: To summarize the inpatient and outpatient revenues to be reported on Worksheet C.

A B C D E F G H I J

Adjusted Adjusted AdjustedCMS Inpatient Outpatient Total Inpatient Outpatient Inpatient Outpatient Inpatient Outpatient TotalLine CMS Description Revenue Revenue Revenue Amount Amount Amount Amount Revenue Revenue Revenue

G.6 G.6 crossfoot C.02 C.02 C.03 C.03 A+D+F B+E+G H+I

Reclassifications Adjustments

Excluded from Worksheet C (include for W/S G Schedules) - - - - - - - - - - 190 GIFT, FLOWER, COFFEE SHOP & CANTEEN - - - - - - - - - -

191.01 RESPITE CARE - - - - - - - - - - 193.01 VENDING MACHINES - - - - - - - - - - 193.02 SUNSET GUEST HOUSE - - - - - - - - - - 193.03 LACEYS RESTAURANT - - - - - - - - - - 193.04 COMMUNITY WELLNESS - - - - - - - - - - 193.05 HOME INFUSION - - - - - - - - - - 193.06 SE HOSP PHYSICIANS LLC 80 38,643,546 38,643,626 - - - (280) 80 38,643,266 38,643,346 193.07 GENERATIONS - - - - - - - - - - 193.08 RETAIL PHARMACY - - - - - - - - - - 193.09 OUTREACH LAB - - - - - - - - - - 193.1 FOOT CLINIC - - - - - - - - - -

193.11 MARKETING - - - - - - - - - - 193.13 HEALTHPOINT - - - - - - - - - - 193.14 DOCTORS PARK - - - - - - - - - -

194 JAZZMANS RESTAURANT - - - - - - - - - - 194.01 FOUNDATION OFFICE - - - - - - - - - -

Total 390,397,501 544,481,080 934,878,581 401,535 (401,535) (11,144,541) (51,864,523) 379,654,495 492,215,022 871,869,517 Total B-1 col 9

Total per Financial Statements: 289,316,603 G.2

Difference - Explain 645,561,978 0

C/A, Bad Debts, Charity 644,914,094 accts grouped in misc income on audit, bad debt/contractuals on CR 647,884 A&P 20,751,278

0 less privateR&B 0 S3.04

0 D-1 line 28 20,751,278Difference - Explain rounding 0


Date/Time Prepared:

Worksheet C

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


Title XIX Hospital Cost

Costs

Cost Center Description Total Cost

(from Wkst.

B, Part I,

col. 26)

Therapy Limit

Adj.

Total Costs RCE

Disallowance

Total Costs

1.00 2.00 3.00 4.00 5.00


30.00 03000 ADULTS & PEDIATRICS 29,782,995 29,782,995 0 29,782,995 30.00

33.01 03301 ADULT SPECIAL CARE 4,394,201 4,394,201 0 4,394,201 33.01

34.01 03401 CARDIOTHORACIC ICU 3,631,943 3,631,943 0 3,631,943 34.01

40.00 04000 SUBPROVIDER - IPF 2,351,542 2,351,542 0 2,351,542 40.00

41.00 04100 SUBPROVIDER - IRF 2,299,362 2,299,362 0 2,299,362 41.00

43.00 04300 NURSERY 1,245,738 1,245,738 0 1,245,738 43.00


50.00 05000 OPERATING ROOM 15,586,078 15,586,078 0 15,586,078 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 2,238,615 2,238,615 0 2,238,615 52.00

53.00 05300 ANESTHESIOLOGY 1,631,157 1,631,157 0 1,631,157 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 6,423,518 6,423,518 0 6,423,518 54.00

54.01 05401 ULTRASOUND 1,136,055 1,136,055 0 1,136,055 54.01

54.03 05403 CARDIOVASCULAR LAB 6,530,084 6,530,084 0 6,530,084 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 6,420,049 6,420,049 0 6,420,049 55.00

55.01 05501 CHEMOTHERAPY 2,111,482 2,111,482 0 2,111,482 55.01

56.01 05601 NUCLEAR MEDICINE 2,262,385 2,262,385 0 2,262,385 56.01

57.00 05700 CT SCAN 3,072,543 3,072,543 0 3,072,543 57.00

58.00 05800 MRI 1,714,527 1,714,527 0 1,714,527 58.00

60.00 06000 LABORATORY 13,350,670 13,350,670 0 13,350,670 60.00

62.30 06250 BLOOD CLOTTING FACTORS FOR HEMOPH. 0 0 0 0 62.30

63.00 06300 BLOOD STORING, PROCESSING & TRANS. 1,193,892 1,193,892 0 1,193,892 63.00

65.00 06500 RESPIRATORY THERAPY 3,588,657 0 3,588,657 0 3,588,657 65.00

66.00 06600 PHYSICAL THERAPY 1,415,988 0 1,415,988 0 1,415,988 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 3,527,704 0 3,527,704 0 3,527,704 66.01

66.02 06602 PHYSIATRY 0 0 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 369,137 0 369,137 0 369,137 67.00

68.00 06800 SPEECH PATHOLOGY 258,428 0 258,428 0 258,428 68.00

69.01 06901 CV DIAGNOSTIC 2,276,534 2,276,534 0 2,276,534 69.01

69.02 06902 ELECTROPHYSIOLOGY LAB 0 0 0 0 69.02

70.01 07001 NEUROPHYSIOLOGY 1,397,467 1,397,467 0 1,397,467 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 14,396,782 14,396,782 0 14,396,782 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 23,486,633 23,486,633 0 23,486,633 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 24,769,451 24,769,451 0 24,769,451 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 655,825 655,825 0 655,825 76.97

76.98 07698 HYPERBARIC OXYGEN THERAPY 0 0 0 0 76.98

76.99 07699 LITHOTRIPSY 0 0 0 0 76.99


88.00 08800 RURAL HEALTH CLINIC 0 0 0 0 88.00

88.01 08801 RURAL HEALTH CLINIC II 4,296,213 4,296,213 0 4,296,213 88.01

88.02 08802 RURAL HEALTH CLINIC III 3,493,914 3,493,914 0 3,493,914 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 831,017 831,017 0 831,017 90.01

90.02 09002 DIABETES CENTER 538,541 538,541 0 538,541 90.02

91.00 09100 EMERGENCY 8,338,703 8,338,703 0 8,338,703 91.00

91.01 09101 G.I. LABORATORY 1,966,085 1,966,085 0 1,966,085 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 4,156,125 4,156,125 4,156,125 92.00


101.00 10100 HOME HEALTH AGENCY 2,171,258 2,171,258 2,171,258 101.00



116.00 11600 HOSPICE 2,838,154 2,838,154 2,838,154 116.00

200.00 Subtotal (see instructions) 212,149,452 0 212,149,452 0 212,149,452 200.00

201.00 Less Observation Beds 4,156,125 4,156,125 4,156,125 201.00

202.00 Total (see instructions) 207,993,327 0 207,993,327 0 207,993,327 202.00


MCRIF32 - 8.8.159.0 101 | Page


Date/Time Prepared:

Worksheet C

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



Charges

Cost Center Description Inpatient Outpatient Total (col. 6

+ col. 7)

Cost or Other

Ratio

TEFRA

Inpatient

Ratio

6.00 7.00 8.00 9.00 10.00


30.00 03000 ADULTS & PEDIATRICS 20,751,278 20,751,278 30.00

33.01 03301 ADULT SPECIAL CARE 6,480,124 6,480,124 33.01

34.01 03401 CARDIOTHORACIC ICU 3,565,208 3,565,208 34.01

40.00 04000 SUBPROVIDER - IPF 2,645,527 2,645,527 40.00

41.00 04100 SUBPROVIDER - IRF 1,384,565 1,384,565 41.00

43.00 04300 NURSERY 2,336,657 2,336,657 43.00


50.00 05000 OPERATING ROOM 45,580,171 43,457,952 89,038,123 0.175049 0.000000 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 4,925,537 751,407 5,676,944 0.394335 0.000000 52.00

53.00 05300 ANESTHESIOLOGY 11,009,625 9,519,599 20,529,224 0.079455 0.000000 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 8,442,901 16,039,886 24,482,787 0.262369 0.000000 54.00

54.01 05401 ULTRASOUND 2,413,498 6,832,089 9,245,587 0.122875 0.000000 54.01

54.03 05403 CARDIOVASCULAR LAB 11,769,736 18,904,647 30,674,383 0.212884 0.000000 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 663,060 15,434,166 16,097,226 0.398830 0.000000 55.00

55.01 05501 CHEMOTHERAPY 13,594 4,077,856 4,091,450 0.516072 0.000000 55.01

56.01 05601 NUCLEAR MEDICINE 1,617,282 17,652,986 19,270,268 0.117403 0.000000 56.01

57.00 05700 CT SCAN 9,650,409 31,770,147 41,420,556 0.074179 0.000000 57.00

58.00 05800 MRI 2,925,525 15,165,832 18,091,357 0.094771 0.000000 58.00

60.00 06000 LABORATORY 34,510,887 40,881,192 75,392,079 0.177083 0.000000 60.00

62.30 06250 BLOOD CLOTTING FACTORS FOR HEMOPH. 0 0 0 0.000000 0.000000 62.30

63.00 06300 BLOOD STORING, PROCESSING & TRANS. 5,449,221 328,884 5,778,105 0.206623 0.000000 63.00

65.00 06500 RESPIRATORY THERAPY 15,378,964 3,621,968 19,000,932 0.188867 0.000000 65.00

66.00 06600 PHYSICAL THERAPY 5,646,346 213,323 5,859,669 0.241650 0.000000 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0 11,560,082 11,560,082 0.305163 0.000000 66.01

66.02 06602 PHYSIATRY 0 0 0 0.000000 0.000000 66.02

67.00 06700 OCCUPATIONAL THERAPY 1,982,677 42,895 2,025,572 0.182238 0.000000 67.00

68.00 06800 SPEECH PATHOLOGY 1,530,995 106,874 1,637,869 0.157783 0.000000 68.00

69.01 06901 CV DIAGNOSTIC 6,884,569 18,390,575 25,275,144 0.090070 0.000000 69.01

69.02 06902 ELECTROPHYSIOLOGY LAB 0 0 0 0.000000 0.000000 69.02

70.01 07001 NEUROPHYSIOLOGY 9,242,230 7,893,729 17,135,959 0.081552 0.000000 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 48,144,602 39,208,019 87,352,621 0.164812 0.000000 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 51,471,593 25,476,120 76,947,713 0.305228 0.000000 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 50,636,568 64,324,947 114,961,515 0.215459 0.000000 73.00

76.00 03950 CARDIAC REHAB 0 0 0 0.000000 0.000000 76.00

76.97 07697 CARDIAC REHABILITATION 9,503 725,279 734,782 0.892544 0.000000 76.97

76.98 07698 HYPERBARIC OXYGEN THERAPY 0 0 0 0.000000 0.000000 76.98

76.99 07699 LITHOTRIPSY 0 0 0 0.000000 0.000000 76.99


88.00 08800 RURAL HEALTH CLINIC 0 0 0 0.000000 0.000000 88.00

88.01 08801 RURAL HEALTH CLINIC II 0 3,642,310 3,642,310 1.179530 0.000000 88.01

88.02 08802 RURAL HEALTH CLINIC III 0 3,451,296 3,451,296 1.012348 0.000000 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 33,150 4,200,574 4,233,724 0.196285 0.000000 90.01

90.02 09002 DIABETES CENTER 231 99,899 100,130 5.378418 0.000000 90.02

91.00 09100 EMERGENCY 7,919,394 31,547,299 39,466,693 0.211285 0.000000 91.00

91.01 09101 G.I. LABORATORY 1,882,726 6,647,244 8,529,970 0.230491 0.000000 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 2,756,062 7,415,870 10,171,932 0.408588 0.000000 92.00


101.00 10100 HOME HEALTH AGENCY 0 1,426,971 1,426,971 101.00



116.00 11600 HOSPICE 0 2,759,839 2,759,839 116.00

200.00 Subtotal (see instructions) 379,654,415 453,571,756 833,226,171 200.00


202.00 Total (see instructions) 379,654,415 453,571,756 833,226,171 202.00


MCRIF32 - 8.8.159.0 102 | Page


Date/Time Prepared:

Worksheet C

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



Cost Center Description PPS Inpatient

Ratio

11.00







43.00 04300 NURSERY 43.00


50.00 05000 OPERATING ROOM 0.000000 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0.000000 52.00

53.00 05300 ANESTHESIOLOGY 0.000000 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0.000000 54.00

54.01 05401 ULTRASOUND 0.000000 54.01

54.03 05403 CARDIOVASCULAR LAB 0.000000 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0.000000 55.00

55.01 05501 CHEMOTHERAPY 0.000000 55.01

56.01 05601 NUCLEAR MEDICINE 0.000000 56.01

57.00 05700 CT SCAN 0.000000 57.00

58.00 05800 MRI 0.000000 58.00

60.00 06000 LABORATORY 0.000000 60.00

62.30 06250 BLOOD CLOTTING FACTORS FOR HEMOPH. 0.000000 62.30

63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0.000000 63.00

65.00 06500 RESPIRATORY THERAPY 0.000000 65.00

66.00 06600 PHYSICAL THERAPY 0.000000 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0.000000 66.01

66.02 06602 PHYSIATRY 0.000000 66.02

67.00 06700 OCCUPATIONAL THERAPY 0.000000 67.00

68.00 06800 SPEECH PATHOLOGY 0.000000 68.00

69.01 06901 CV DIAGNOSTIC 0.000000 69.01

69.02 06902 ELECTROPHYSIOLOGY LAB 0.000000 69.02

70.01 07001 NEUROPHYSIOLOGY 0.000000 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 0.000000 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0.000000 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 0.000000 73.00

76.00 03950 CARDIAC REHAB 0.000000 76.00

76.97 07697 CARDIAC REHABILITATION 0.000000 76.97

76.98 07698 HYPERBARIC OXYGEN THERAPY 0.000000 76.98

76.99 07699 LITHOTRIPSY 0.000000 76.99


88.00 08800 RURAL HEALTH CLINIC 0.000000 88.00

88.01 08801 RURAL HEALTH CLINIC II 0.000000 88.01

88.02 08802 RURAL HEALTH CLINIC III 0.000000 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 0.000000 90.01

90.02 09002 DIABETES CENTER 0.000000 90.02

91.00 09100 EMERGENCY 0.000000 91.00

91.01 09101 G.I. LABORATORY 0.000000 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 0.000000 92.00





116.00 11600 HOSPICE 116.00

200.00 Subtotal (see instructions) 200.00


202.00 Total (see instructions) 202.00


MCRIF32 - 8.8.159.0 103 | Page


Date/Time Prepared:

Worksheet D

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110APPORTIONMENT OF INPATIENT ROUTINE SERVICE CAPITAL COSTS


Cost Center Description Capital

Related Cost

(from Wkst.

B, Part II,

col. 26)

Swing Bed

Adjustment

Reduced

Capital

Related Cost

(col. 1 -

col. 2)

Total Patient

Days

Per Diem

(col. 3 /

col. 4)

1.00 2.00 3.00 4.00 5.00


30.00 ADULTS & PEDIATRICS 4,790,998 0 4,790,998 32,405 147.85 30.00

33.01 ADULT SPECIAL CARE 643,630 643,630 2,666 241.42 33.01

34.01 CARDIOTHORACIC ICU 847,937 847,937 2,024 418.94 34.01

40.00 SUBPROVIDER - IPF 346,718 0 346,718 2,928 118.41 40.00

41.00 SUBPROVIDER - IRF 377,716 0 377,716 2,348 160.87 41.00

43.00 NURSERY 154,104 154,104 2,858 53.92 43.00

200.00 Total (lines 30-199) 7,161,103 7,161,103 45,229 200.00

Cost Center Description Inpatient

Program days

Inpatient

Program

Capital Cost

(col. 5 x

col. 6)

6.00 7.00


30.00 ADULTS & PEDIATRICS 16,163 2,389,700 30.00

33.01 ADULT SPECIAL CARE 1,492 360,199 33.01

34.01 CARDIOTHORACIC ICU 1,135 475,497 34.01

40.00 SUBPROVIDER - IPF 936 110,832 40.00

41.00 SUBPROVIDER - IRF 1,615 259,805 41.00

43.00 NURSERY 0 0 43.00

200.00 Total (lines 30-199) 21,341 3,596,033 200.00


MCRIF32 - 8.8.159.0 104 | Page


Date/Time Prepared:

Worksheet D

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110APPORTIONMENT OF INPATIENT ANCILLARY SERVICE CAPITAL COSTS



Related Cost

(from Wkst.

B, Part II,

col. 26)

Total Charges

(from Wkst.

C, Part I,

col. 8)

Ratio of Cost

to Charges

(col. 1 ÷

col. 2)

Inpatient

Program

Charges

Capital Costs

(column 3 x

column 4)

1.00 2.00 3.00 4.00 5.00


50.00 05000 OPERATING ROOM 3,121,731 89,038,123 0.035061 27,656,867 969,677 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 273,222 5,676,944 0.048128 9,052 436 52.00

53.00 05300 ANESTHESIOLOGY 511,168 20,529,224 0.024900 5,778,020 143,873 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 1,254,660 24,482,787 0.051247 5,162,270 264,551 54.00

54.01 05401 ULTRASOUND 185,287 9,245,587 0.020041 1,405,967 28,177 54.01

54.03 05403 CARDIOVASCULAR LAB 1,548,955 30,674,383 0.050497 6,910,180 348,943 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 2,536,760 16,097,226 0.157590 386,879 60,968 55.00

55.01 05501 CHEMOTHERAPY 594,845 4,091,450 0.145387 10,156 1,477 55.01

56.01 05601 NUCLEAR MEDICINE 273,525 19,270,268 0.014194 1,053,229 14,950 56.01

57.00 05700 CT SCAN 1,127,280 41,420,556 0.027215 6,226,318 169,449 57.00

58.00 05800 MRI 625,989 18,091,357 0.034602 1,755,001 60,727 58.00

60.00 06000 LABORATORY 1,306,909 75,392,079 0.017335 20,507,116 355,491 60.00

62.30 06250 BLOOD CLOTTING FACTORS FOR HEMOPH. 0 0 0.000000 0 0 62.30

63.00 06300 BLOOD STORING, PROCESSING & TRANS. 59,258 5,778,105 0.010256 3,322,670 34,077 63.00

65.00 06500 RESPIRATORY THERAPY 421,144 19,000,932 0.022164 9,492,256 210,386 65.00

66.00 06600 PHYSICAL THERAPY 120,450 5,859,669 0.020556 2,714,944 55,808 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 501,699 11,560,082 0.043399 0 0 66.01

66.02 06602 PHYSIATRY 0 0 0.000000 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 29,703 2,025,572 0.014664 455,893 6,685 67.00

68.00 06800 SPEECH PATHOLOGY 16,585 1,637,869 0.010126 600,112 6,077 68.00

69.01 06901 CV DIAGNOSTIC 219,030 25,275,144 0.008666 4,442,839 38,502 69.01

69.02 06902 ELECTROPHYSIOLOGY LAB 0 0 0.000000 0 0 69.02

70.01 07001 NEUROPHYSIOLOGY 263,619 17,135,959 0.015384 4,482,768 68,963 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 560,974 87,352,621 0.006422 24,864,691 159,681 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 1,214,779 76,947,713 0.015787 27,152,313 428,654 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 1,536,566 114,961,515 0.013366 25,815,579 345,051 73.00

76.00 03950 CARDIAC REHAB 0 0 0.000000 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 101,048 734,782 0.137521 5,241 721 76.97

76.98 07698 HYPERBARIC OXYGEN THERAPY 0 0 0.000000 0 0 76.98

76.99 07699 LITHOTRIPSY 0 0 0.000000 0 0 76.99


88.00 08800 RURAL HEALTH CLINIC 0 0 0.000000 0 0 88.00

88.01 08801 RURAL HEALTH CLINIC II 568,489 3,642,310 0.156079 0 0 88.01

88.02 08802 RURAL HEALTH CLINIC III 401,278 3,451,296 0.116269 0 0 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 79,253 4,233,724 0.018719 0 0 90.01

90.02 09002 DIABETES CENTER 138,954 100,130 1.387736 0 0 90.02

91.00 09100 EMERGENCY 1,173,426 39,466,693 0.029732 5,210,873 154,930 91.00

91.01 09101 G.I. LABORATORY 665,439 8,529,970 0.078012 1,087,125 84,809 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 668,571 10,171,932 0.065727 1,398,751 91,936 92.00

200.00 Total (lines 50-199) 22,100,596 791,876,002 187,907,110 4,104,999 200.00


MCRIF32 - 8.8.159.0 105 | Page


Date/Time Prepared:

Worksheet D

Part III

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110APPORTIONMENT OF INPATIENT ROUTINE SERVICE OTHER PASS THROUGH COSTS


Cost Center Description Nursing

School

Allied Health

Cost

All Other

Medical

Education

Cost

Swing-Bed

Adjustment

Amount (see

instructions)

Total Costs

(sum of cols.

1 through 3,

minus col. 4)

1.00 2.00 3.00 4.00 5.00


30.00 03000 ADULTS & PEDIATRICS 660,621 0 0 0 660,621 30.00

33.01 03301 ADULT SPECIAL CARE 0 0 0 0 33.01

34.01 03401 CARDIOTHORACIC ICU 29,591 0 0 29,591 34.01

40.00 04000 SUBPROVIDER - IPF 66,664 0 0 0 66,664 40.00

41.00 04100 SUBPROVIDER - IRF 49,477 0 0 0 49,477 41.00

43.00 04300 NURSERY 0 0 0 0 43.00

200.00 Total (lines 30-199) 806,353 0 0 806,353 200.00

Cost Center Description Total Patient

Days

Per Diem

(col. 5 ÷

col. 6)

Inpatient

Program Days

Inpatient

Program

Pass-Through

Cost (col. 7

x col. 8)

6.00 7.00 8.00 9.00


30.00 03000 ADULTS & PEDIATRICS 32,405 20.39 16,163 329,564 30.00

33.01 03301 ADULT SPECIAL CARE 2,666 0.00 1,492 0 33.01

34.01 03401 CARDIOTHORACIC ICU 2,024 14.62 1,135 16,594 34.01

40.00 04000 SUBPROVIDER - IPF 2,928 22.77 936 21,313 40.00

41.00 04100 SUBPROVIDER - IRF 2,348 21.07 1,615 34,028 41.00

43.00 04300 NURSERY 2,858 0.00 0 0 43.00

200.00 Total (lines 30-199) 45,229 21,341 401,499 200.00


MCRIF32 - 8.8.159.0 106 | Page


Date/Time Prepared:

Worksheet D

Part IV

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110APPORTIONMENT OF INPATIENT/OUTPATIENT ANCILLARY SERVICE OTHER PASS

THROUGH COSTS


Cost Center Description Non Physician

Anesthetist

Cost

Nursing

School

Allied Health All Other

Medical

Education

Cost

Total Cost

(sum of col 1

through col.

4)

1.00 2.00 3.00 4.00 5.00


50.00 05000 OPERATING ROOM 0 57,034 0 0 57,034 50.00


53.00 05300 ANESTHESIOLOGY 0 0 0 0 0 53.00


54.01 05401 ULTRASOUND 0 0 0 0 0 54.01



55.01 05501 CHEMOTHERAPY 0 0 0 0 0 55.01


57.00 05700 CT SCAN 0 0 0 0 0 57.00

58.00 05800 MRI 0 0 0 0 0 58.00

60.00 06000 LABORATORY 0 78,644 0 0 78,644 60.00






66.02 06602 PHYSIATRY 0 0 0 0 0 66.02



69.01 06901 CV DIAGNOSTIC 0 0 0 0 0 69.01






76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00



76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99






90.02 09002 DIABETES CENTER 0 0 0 0 0 90.02

91.00 09100 EMERGENCY 0 45,689 0 0 45,689 91.00

91.01 09101 G.I. LABORATORY 0 0 0 0 0 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 0 92,187 0 0 92,187 92.00

200.00 Total (lines 50-199) 0 393,835 0 0 393,835 200.00


MCRIF32 - 8.8.159.0 107 | Page


Date/Time Prepared:

Worksheet D

Part IV

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


THROUGH COSTS


Cost Center Description Total

Outpatient

Cost (sum of

col. 2, 3 and

4)

Total Charges

(from Wkst.

C, Part I,

col. 8)

Ratio of Cost

to Charges

(col. 5 ÷

col. 7)

Outpatient

Ratio of Cost

to Charges

(col. 6 ÷

col. 7)

Inpatient

Program

Charges

6.00 7.00 8.00 9.00 10.00


50.00 05000 OPERATING ROOM 57,034 89,038,123 0.000641 0.000641 27,656,867 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0 5,676,944 0.000000 0.000000 9,052 52.00

53.00 05300 ANESTHESIOLOGY 0 20,529,224 0.000000 0.000000 5,778,020 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 113,889 24,482,787 0.004652 0.004652 5,162,270 54.00

54.01 05401 ULTRASOUND 0 9,245,587 0.000000 0.000000 1,405,967 54.01

54.03 05403 CARDIOVASCULAR LAB 6,392 30,674,383 0.000208 0.000208 6,910,180 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0 16,097,226 0.000000 0.000000 386,879 55.00

55.01 05501 CHEMOTHERAPY 0 4,091,450 0.000000 0.000000 10,156 55.01

56.01 05601 NUCLEAR MEDICINE 0 19,270,268 0.000000 0.000000 1,053,229 56.01

57.00 05700 CT SCAN 0 41,420,556 0.000000 0.000000 6,226,318 57.00

58.00 05800 MRI 0 18,091,357 0.000000 0.000000 1,755,001 58.00

60.00 06000 LABORATORY 78,644 75,392,079 0.001043 0.001043 20,507,116 60.00

62.30 06250 BLOOD CLOTTING FACTORS FOR HEMOPH. 0 0 0.000000 0.000000 0 62.30

63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0 5,778,105 0.000000 0.000000 3,322,670 63.00

65.00 06500 RESPIRATORY THERAPY 0 19,000,932 0.000000 0.000000 9,492,256 65.00

66.00 06600 PHYSICAL THERAPY 0 5,859,669 0.000000 0.000000 2,714,944 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0 11,560,082 0.000000 0.000000 0 66.01

66.02 06602 PHYSIATRY 0 0 0.000000 0.000000 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 0 2,025,572 0.000000 0.000000 455,893 67.00

68.00 06800 SPEECH PATHOLOGY 0 1,637,869 0.000000 0.000000 600,112 68.00

69.01 06901 CV DIAGNOSTIC 0 25,275,144 0.000000 0.000000 4,442,839 69.01

69.02 06902 ELECTROPHYSIOLOGY LAB 0 0 0.000000 0.000000 0 69.02

70.01 07001 NEUROPHYSIOLOGY 0 17,135,959 0.000000 0.000000 4,482,768 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 0 87,352,621 0.000000 0.000000 24,864,691 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0 76,947,713 0.000000 0.000000 27,152,313 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 0 114,961,515 0.000000 0.000000 25,815,579 73.00

76.00 03950 CARDIAC REHAB 0 0 0.000000 0.000000 0 76.00

76.97 07697 CARDIAC REHABILITATION 0 734,782 0.000000 0.000000 5,241 76.97

76.98 07698 HYPERBARIC OXYGEN THERAPY 0 0 0.000000 0.000000 0 76.98

76.99 07699 LITHOTRIPSY 0 0 0.000000 0.000000 0 76.99


88.00 08800 RURAL HEALTH CLINIC 0 0 0.000000 0.000000 0 88.00

88.01 08801 RURAL HEALTH CLINIC II 0 3,642,310 0.000000 0.000000 0 88.01

88.02 08802 RURAL HEALTH CLINIC III 0 3,451,296 0.000000 0.000000 0 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 0 4,233,724 0.000000 0.000000 0 90.01

90.02 09002 DIABETES CENTER 0 100,130 0.000000 0.000000 0 90.02

91.00 09100 EMERGENCY 45,689 39,466,693 0.001158 0.001158 5,210,873 91.00

91.01 09101 G.I. LABORATORY 0 8,529,970 0.000000 0.000000 1,087,125 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 92,187 10,171,932 0.009063 0.009063 1,398,751 92.00

200.00 Total (lines 50-199) 393,835 791,876,002 187,907,110 200.00


MCRIF32 - 8.8.159.0 108 | Page


Date/Time Prepared:

Worksheet D

Part IV

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015


THROUGH COSTS



Program

Pass-Through

Costs (col. 8

x col. 10)

Outpatient

Program

Charges

Outpatient

Program

Pass-Through

Costs (col. 9

x col. 12)

11.00 12.00 13.00


50.00 05000 OPERATING ROOM 17,728 12,966,998 8,312 50.00


53.00 05300 ANESTHESIOLOGY 0 2,467,011 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 24,015 5,111,979 23,781 54.00

54.01 05401 ULTRASOUND 0 1,678,591 0 54.01

54.03 05403 CARDIOVASCULAR LAB 1,437 10,816,073 2,250 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0 7,705,111 0 55.00

55.01 05501 CHEMOTHERAPY 0 2,071,149 0 55.01

56.01 05601 NUCLEAR MEDICINE 0 9,684,872 0 56.01

57.00 05700 CT SCAN 0 13,662,770 0 57.00

58.00 05800 MRI 0 5,918,798 0 58.00

60.00 06000 LABORATORY 21,389 10,465,591 10,916 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0 75,375 0 63.00

65.00 06500 RESPIRATORY THERAPY 0 1,557,222 0 65.00

66.00 06600 PHYSICAL THERAPY 0 31,565 0 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0 13,304 0 66.01

66.02 06602 PHYSIATRY 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 0 12,214 0 67.00

68.00 06800 SPEECH PATHOLOGY 0 45,419 0 68.00

69.01 06901 CV DIAGNOSTIC 0 9,606,490 0 69.01


70.01 07001 NEUROPHYSIOLOGY 0 2,588,051 0 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 0 13,485,171 0 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0 12,930,965 0 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 0 25,858,680 0 73.00

76.00 03950 CARDIAC REHAB 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 0 378,324 0 76.97


76.99 07699 LITHOTRIPSY 0 0 0 76.99





90.01 09001 HYPERBARIC WOUND CLINIC 0 2,634,946 0 90.01

90.02 09002 DIABETES CENTER 0 2,539 0 90.02

91.00 09100 EMERGENCY 6,034 6,523,880 7,555 91.00

91.01 09101 G.I. LABORATORY 0 2,409,549 0 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 12,677 2,153,870 19,521 92.00

200.00 Total (lines 50-199) 83,280 162,857,500 72,335 200.00


MCRIF32 - 8.8.159.0 109 | Page


Date/Time Prepared:

Worksheet D

Part V

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES AND VACCINE COST


Charges Costs

Cost Center Description Cost to

Charge Ratio

From

Worksheet C,

Part I, col.

9

PPS

Reimbursed

Services (see

inst.)

Cost

Reimbursed

Services

Subject To

Ded. & Coins.

(see inst.)

Cost

Reimbursed

Services Not

Subject To

Ded. & Coins.

(see inst.)

PPS Services

(see inst.)

1.00 2.00 3.00 4.00 5.00


50.00 05000 OPERATING ROOM 0.175049 12,966,998 0 0 2,269,860 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0.394335 993 0 0 392 52.00

53.00 05300 ANESTHESIOLOGY 0.079455 2,467,011 0 0 196,016 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0.262369 5,111,979 0 0 1,341,225 54.00

54.01 05401 ULTRASOUND 0.122875 1,678,591 0 0 206,257 54.01

54.03 05403 CARDIOVASCULAR LAB 0.212884 10,816,073 0 0 2,302,569 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0.398830 7,705,111 0 0 3,073,029 55.00

55.01 05501 CHEMOTHERAPY 0.516072 2,071,149 0 0 1,068,862 55.01

56.01 05601 NUCLEAR MEDICINE 0.117403 9,684,872 0 0 1,137,033 56.01

57.00 05700 CT SCAN 0.074179 13,662,770 0 0 1,013,491 57.00

58.00 05800 MRI 0.094771 5,918,798 0 0 560,930 58.00

60.00 06000 LABORATORY 0.177083 10,465,591 34,997 0 1,853,278 60.00

62.30 06250 BLOOD CLOTTING FACTORS FOR HEMOPH. 0.000000 0 0 0 0 62.30

63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0.206623 75,375 0 0 15,574 63.00

65.00 06500 RESPIRATORY THERAPY 0.188867 1,557,222 0 0 294,108 65.00

66.00 06600 PHYSICAL THERAPY 0.241650 31,565 0 0 7,628 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0.305163 13,304 0 0 4,060 66.01

66.02 06602 PHYSIATRY 0.000000 0 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 0.182238 12,214 0 0 2,226 67.00

68.00 06800 SPEECH PATHOLOGY 0.157783 45,419 0 0 7,166 68.00

69.01 06901 CV DIAGNOSTIC 0.090070 9,606,490 0 0 865,257 69.01

69.02 06902 ELECTROPHYSIOLOGY LAB 0.000000 0 0 0 0 69.02

70.01 07001 NEUROPHYSIOLOGY 0.081552 2,588,051 0 0 211,061 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 0.164812 13,485,171 0 0 2,222,518 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0.305228 12,930,965 0 0 3,946,893 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 0.215459 25,858,680 0 129,121 5,571,485 73.00

76.00 03950 CARDIAC REHAB 0.000000 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 0.892544 378,324 0 0 337,671 76.97

76.98 07698 HYPERBARIC OXYGEN THERAPY 0.000000 0 0 0 0 76.98

76.99 07699 LITHOTRIPSY 0.000000 0 0 0 0 76.99


88.00 08800 RURAL HEALTH CLINIC 0.000000 0 88.00

88.01 08801 RURAL HEALTH CLINIC II 0.000000 0 88.01

88.02 08802 RURAL HEALTH CLINIC III 0.000000 0 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 0.196285 2,634,946 0 0 517,200 90.01

90.02 09002 DIABETES CENTER 5.378418 2,539 0 0 13,656 90.02

91.00 09100 EMERGENCY 0.211285 6,523,880 0 0 1,378,398 91.00

91.01 09101 G.I. LABORATORY 0.230491 2,409,549 0 0 555,379 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 0.408588 2,153,870 0 0 880,045 92.00

200.00 Subtotal (see instructions) 162,857,500 34,997 129,121 31,853,267 200.00

201.00 Less PBP Clinic Lab. Services-Program

Only Charges

0 0 201.00

202.00 Net Charges (line 200 +/- line 201) 162,857,500 34,997 129,121 31,853,267 202.00


MCRIF32 - 8.8.159.0 110 | Page


Date/Time Prepared:

Worksheet D

Part V

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



Costs

Cost Center Description Cost

Reimbursed

Services

Subject To

Ded. & Coins.

(see inst.)

Cost

Reimbursed

Services Not

Subject To

Ded. & Coins.

(see inst.)

6.00 7.00


50.00 05000 OPERATING ROOM 0 0 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0 0 52.00

53.00 05300 ANESTHESIOLOGY 0 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0 0 54.00

54.01 05401 ULTRASOUND 0 0 54.01

54.03 05403 CARDIOVASCULAR LAB 0 0 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0 0 55.00

55.01 05501 CHEMOTHERAPY 0 0 55.01

56.01 05601 NUCLEAR MEDICINE 0 0 56.01

57.00 05700 CT SCAN 0 0 57.00

58.00 05800 MRI 0 0 58.00

60.00 06000 LABORATORY 6,197 0 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0 0 63.00

65.00 06500 RESPIRATORY THERAPY 0 0 65.00

66.00 06600 PHYSICAL THERAPY 0 0 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0 0 66.01

66.02 06602 PHYSIATRY 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 0 0 67.00

68.00 06800 SPEECH PATHOLOGY 0 0 68.00

69.01 06901 CV DIAGNOSTIC 0 0 69.01


70.01 07001 NEUROPHYSIOLOGY 0 0 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 0 0 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0 0 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 0 27,820 73.00

76.00 03950 CARDIAC REHAB 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 0 0 76.97


76.99 07699 LITHOTRIPSY 0 0 76.99



88.01 08801 RURAL HEALTH CLINIC II 0 0 88.01

88.02 08802 RURAL HEALTH CLINIC III 0 0 88.02

90.01 09001 HYPERBARIC WOUND CLINIC 0 0 90.01

90.02 09002 DIABETES CENTER 0 0 90.02

91.00 09100 EMERGENCY 0 0 91.00

91.01 09101 G.I. LABORATORY 0 0 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 0 0 92.00

200.00 Subtotal (see instructions) 6,197 27,820 200.00


Only Charges

0 201.00

202.00 Net Charges (line 200 +/- line 201) 6,197 27,820 202.00


MCRIF32 - 8.8.159.0 111 | Page


Date/Time Prepared:

Worksheet D

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Component CCN:26S110

APPORTIONMENT OF INPATIENT ANCILLARY SERVICE CAPITAL COSTS

Title XVIII Subprovider -

IPF

PPS


Related Cost

(from Wkst.

B, Part II,

col. 26)

Total Charges

(from Wkst.

C, Part I,

col. 8)

Ratio of Cost

to Charges

(col. 1 ÷

col. 2)

Inpatient

Program

Charges

Capital Costs

(column 3 x

column 4)

1.00 2.00 3.00 4.00 5.00


50.00 05000 OPERATING ROOM 3,121,731 89,038,123 0.035061 0 0 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 273,222 5,676,944 0.048128 0 0 52.00

53.00 05300 ANESTHESIOLOGY 511,168 20,529,224 0.024900 0 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 1,254,660 24,482,787 0.051247 5,476 281 54.00

54.01 05401 ULTRASOUND 185,287 9,245,587 0.020041 13,036 261 54.01

54.03 05403 CARDIOVASCULAR LAB 1,548,955 30,674,383 0.050497 0 0 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 2,536,760 16,097,226 0.157590 0 0 55.00

55.01 05501 CHEMOTHERAPY 594,845 4,091,450 0.145387 0 0 55.01

56.01 05601 NUCLEAR MEDICINE 273,525 19,270,268 0.014194 0 0 56.01

57.00 05700 CT SCAN 1,127,280 41,420,556 0.027215 15,174 413 57.00

58.00 05800 MRI 625,989 18,091,357 0.034602 6,923 240 58.00

60.00 06000 LABORATORY 1,306,909 75,392,079 0.017335 192,020 3,329 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 59,258 5,778,105 0.010256 0 0 63.00

65.00 06500 RESPIRATORY THERAPY 421,144 19,000,932 0.022164 65,853 1,460 65.00

66.00 06600 PHYSICAL THERAPY 120,450 5,859,669 0.020556 37,884 779 66.00


66.02 06602 PHYSIATRY 0 0 0.000000 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 29,703 2,025,572 0.014664 1,462 21 67.00

68.00 06800 SPEECH PATHOLOGY 16,585 1,637,869 0.010126 12,355 125 68.00

69.01 06901 CV DIAGNOSTIC 219,030 25,275,144 0.008666 2,230 19 69.01


70.01 07001 NEUROPHYSIOLOGY 263,619 17,135,959 0.015384 0 0 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 560,974 87,352,621 0.006422 0 0 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 1,214,779 76,947,713 0.015787 0 0 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 1,536,566 114,961,515 0.013366 436,679 5,837 73.00

76.00 03950 CARDIAC REHAB 0 0 0.000000 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 101,048 734,782 0.137521 0 0 76.97


76.99 07699 LITHOTRIPSY 0 0 0.000000 0 0 76.99






90.02 09002 DIABETES CENTER 138,954 100,130 1.387736 0 0 90.02

91.00 09100 EMERGENCY 1,173,426 39,466,693 0.029732 0 0 91.00

91.01 09101 G.I. LABORATORY 665,439 8,529,970 0.078012 0 0 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 0 10,171,932 0.000000 0 0 92.00

200.00 Total (lines 50-199) 21,432,025 791,876,002 789,092 12,765 200.00


MCRIF32 - 8.8.159.0 112 | Page


Date/Time Prepared:

Worksheet D

Part IV

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110


APPORTIONMENT OF INPATIENT/OUTPATIENT ANCILLARY SERVICE OTHER PASS

THROUGH COSTS


IPF

PPS


Anesthetist

Cost

Nursing

School


Medical

Education

Cost

Total Cost

(sum of col 1

through col.

4)

1.00 2.00 3.00 4.00 5.00


50.00 05000 OPERATING ROOM 0 57,034 0 0 57,034 50.00


53.00 05300 ANESTHESIOLOGY 0 0 0 0 0 53.00


54.01 05401 ULTRASOUND 0 0 0 0 0 54.01



55.01 05501 CHEMOTHERAPY 0 0 0 0 0 55.01


57.00 05700 CT SCAN 0 0 0 0 0 57.00

58.00 05800 MRI 0 0 0 0 0 58.00

60.00 06000 LABORATORY 0 78,644 0 0 78,644 60.00






66.02 06602 PHYSIATRY 0 0 0 0 0 66.02



69.01 06901 CV DIAGNOSTIC 0 0 0 0 0 69.01






76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00



76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99






90.02 09002 DIABETES CENTER 0 0 0 0 0 90.02

91.00 09100 EMERGENCY 0 45,689 0 0 45,689 91.00

91.01 09101 G.I. LABORATORY 0 0 0 0 0 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 0 0 0 0 0 92.00

200.00 Total (lines 50-199) 0 301,648 0 0 301,648 200.00


MCRIF32 - 8.8.159.0 113 | Page


Date/Time Prepared:

Worksheet D

Part IV

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110



THROUGH COSTS


IPF

PPS


Outpatient

Cost (sum of

col. 2, 3 and

4)

Total Charges

(from Wkst.

C, Part I,

col. 8)

Ratio of Cost

to Charges

(col. 5 ÷

col. 7)

Outpatient

Ratio of Cost

to Charges

(col. 6 ÷

col. 7)

Inpatient

Program

Charges

6.00 7.00 8.00 9.00 10.00


50.00 05000 OPERATING ROOM 57,034 89,038,123 0.000641 0.000641 0 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0 5,676,944 0.000000 0.000000 0 52.00

53.00 05300 ANESTHESIOLOGY 0 20,529,224 0.000000 0.000000 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 113,889 24,482,787 0.004652 0.004652 5,476 54.00

54.01 05401 ULTRASOUND 0 9,245,587 0.000000 0.000000 13,036 54.01

54.03 05403 CARDIOVASCULAR LAB 6,392 30,674,383 0.000208 0.000208 0 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0 16,097,226 0.000000 0.000000 0 55.00

55.01 05501 CHEMOTHERAPY 0 4,091,450 0.000000 0.000000 0 55.01

56.01 05601 NUCLEAR MEDICINE 0 19,270,268 0.000000 0.000000 0 56.01

57.00 05700 CT SCAN 0 41,420,556 0.000000 0.000000 15,174 57.00

58.00 05800 MRI 0 18,091,357 0.000000 0.000000 6,923 58.00

60.00 06000 LABORATORY 78,644 75,392,079 0.001043 0.001043 192,020 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0 5,778,105 0.000000 0.000000 0 63.00

65.00 06500 RESPIRATORY THERAPY 0 19,000,932 0.000000 0.000000 65,853 65.00

66.00 06600 PHYSICAL THERAPY 0 5,859,669 0.000000 0.000000 37,884 66.00


66.02 06602 PHYSIATRY 0 0 0.000000 0.000000 0 66.02



69.01 06901 CV DIAGNOSTIC 0 25,275,144 0.000000 0.000000 2,230 69.01


70.01 07001 NEUROPHYSIOLOGY 0 17,135,959 0.000000 0.000000 0 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 0 87,352,621 0.000000 0.000000 0 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0 76,947,713 0.000000 0.000000 0 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 0 114,961,515 0.000000 0.000000 436,679 73.00

76.00 03950 CARDIAC REHAB 0 0 0.000000 0.000000 0 76.00

76.97 07697 CARDIAC REHABILITATION 0 734,782 0.000000 0.000000 0 76.97


76.99 07699 LITHOTRIPSY 0 0 0.000000 0.000000 0 76.99






90.02 09002 DIABETES CENTER 0 100,130 0.000000 0.000000 0 90.02

91.00 09100 EMERGENCY 45,689 39,466,693 0.001158 0.001158 0 91.00

91.01 09101 G.I. LABORATORY 0 8,529,970 0.000000 0.000000 0 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 0 10,171,932 0.000000 0.000000 0 92.00

200.00 Total (lines 50-199) 301,648 791,876,002 789,092 200.00


MCRIF32 - 8.8.159.0 114 | Page


Date/Time Prepared:

Worksheet D

Part IV

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110



THROUGH COSTS


IPF

PPS


Program

Pass-Through

Costs (col. 8

x col. 10)

Outpatient

Program

Charges

Outpatient

Program

Pass-Through

Costs (col. 9

x col. 12)

11.00 12.00 13.00


50.00 05000 OPERATING ROOM 0 0 0 50.00


53.00 05300 ANESTHESIOLOGY 0 0 0 53.00


54.01 05401 ULTRASOUND 0 0 0 54.01



55.01 05501 CHEMOTHERAPY 0 0 0 55.01


57.00 05700 CT SCAN 0 3,928 0 57.00

58.00 05800 MRI 0 0 0 58.00

60.00 06000 LABORATORY 200 0 0 60.00






66.02 06602 PHYSIATRY 0 0 0 66.02



69.01 06901 CV DIAGNOSTIC 0 609 0 69.01





73.00 07300 DRUGS CHARGED TO PATIENTS 0 209 0 73.00

76.00 03950 CARDIAC REHAB 0 0 0 76.00



76.99 07699 LITHOTRIPSY 0 0 0 76.99






90.02 09002 DIABETES CENTER 0 0 0 90.02

91.00 09100 EMERGENCY 0 0 0 91.00

91.01 09101 G.I. LABORATORY 0 0 0 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 0 0 0 92.00

200.00 Total (lines 50-199) 225 5,203 2 200.00


MCRIF32 - 8.8.159.0 115 | Page


Date/Time Prepared:

Worksheet D

Part V

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110


APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES AND VACCINE COST


IPF

PPS

Charges Costs


Charge Ratio

From

Worksheet C,

Part I, col.

9

PPS

Reimbursed

Services (see

inst.)

Cost

Reimbursed

Services

Subject To

Ded. & Coins.

(see inst.)

Cost

Reimbursed

Services Not

Subject To

Ded. & Coins.

(see inst.)

PPS Services

(see inst.)

1.00 2.00 3.00 4.00 5.00


50.00 05000 OPERATING ROOM 0.175049 0 0 0 0 50.00


53.00 05300 ANESTHESIOLOGY 0.079455 0 0 0 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0.262369 457 0 0 120 54.00

54.01 05401 ULTRASOUND 0.122875 0 0 0 0 54.01

54.03 05403 CARDIOVASCULAR LAB 0.212884 0 0 0 0 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0.398830 0 0 0 0 55.00

55.01 05501 CHEMOTHERAPY 0.516072 0 0 0 0 55.01

56.01 05601 NUCLEAR MEDICINE 0.117403 0 0 0 0 56.01

57.00 05700 CT SCAN 0.074179 3,928 0 0 291 57.00

58.00 05800 MRI 0.094771 0 0 0 0 58.00

60.00 06000 LABORATORY 0.177083 0 0 0 0 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0.206623 0 0 0 0 63.00

65.00 06500 RESPIRATORY THERAPY 0.188867 0 0 0 0 65.00

66.00 06600 PHYSICAL THERAPY 0.241650 0 0 0 0 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0.305163 0 0 0 0 66.01

66.02 06602 PHYSIATRY 0.000000 0 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 0.182238 0 0 0 0 67.00

68.00 06800 SPEECH PATHOLOGY 0.157783 0 0 0 0 68.00

69.01 06901 CV DIAGNOSTIC 0.090070 609 0 0 55 69.01


70.01 07001 NEUROPHYSIOLOGY 0.081552 0 0 0 0 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 0.164812 0 0 0 0 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0.305228 0 0 0 0 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 0.215459 209 0 198 45 73.00

76.00 03950 CARDIAC REHAB 0.000000 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 0.892544 0 0 0 0 76.97


76.99 07699 LITHOTRIPSY 0.000000 0 0 0 0 76.99





90.01 09001 HYPERBARIC WOUND CLINIC 0.196285 0 0 0 0 90.01

90.02 09002 DIABETES CENTER 5.378418 0 0 0 0 90.02

91.00 09100 EMERGENCY 0.211285 0 0 0 0 91.00

91.01 09101 G.I. LABORATORY 0.230491 0 0 0 0 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 0.408588 0 0 0 0 92.00

200.00 Subtotal (see instructions) 5,203 0 198 511 200.00


Only Charges

0 0 201.00

202.00 Net Charges (line 200 +/- line 201) 5,203 0 198 511 202.00


MCRIF32 - 8.8.159.0 116 | Page


Date/Time Prepared:

Worksheet D

Part V

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110




IPF

PPS

Costs


Reimbursed

Services

Subject To

Ded. & Coins.

(see inst.)

Cost

Reimbursed

Services Not

Subject To

Ded. & Coins.

(see inst.)

6.00 7.00


50.00 05000 OPERATING ROOM 0 0 50.00


53.00 05300 ANESTHESIOLOGY 0 0 53.00


54.01 05401 ULTRASOUND 0 0 54.01



55.01 05501 CHEMOTHERAPY 0 0 55.01


57.00 05700 CT SCAN 0 0 57.00

58.00 05800 MRI 0 0 58.00

60.00 06000 LABORATORY 0 0 60.00






66.02 06602 PHYSIATRY 0 0 66.02



69.01 06901 CV DIAGNOSTIC 0 0 69.01





73.00 07300 DRUGS CHARGED TO PATIENTS 0 43 73.00

76.00 03950 CARDIAC REHAB 0 0 76.00



76.99 07699 LITHOTRIPSY 0 0 76.99






90.02 09002 DIABETES CENTER 0 0 90.02

91.00 09100 EMERGENCY 0 0 91.00

91.01 09101 G.I. LABORATORY 0 0 91.01


200.00 Subtotal (see instructions) 0 43 200.00


Only Charges

0 201.00

202.00 Net Charges (line 200 +/- line 201) 0 43 202.00


MCRIF32 - 8.8.159.0 117 | Page


Date/Time Prepared:

Worksheet D

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Component CCN:26T110

APPORTIONMENT OF INPATIENT ANCILLARY SERVICE CAPITAL COSTS


IRF

PPS


Related Cost

(from Wkst.

B, Part II,

col. 26)

Total Charges

(from Wkst.

C, Part I,

col. 8)

Ratio of Cost

to Charges

(col. 1 ÷

col. 2)

Inpatient

Program

Charges

Capital Costs

(column 3 x

column 4)

1.00 2.00 3.00 4.00 5.00


50.00 05000 OPERATING ROOM 3,121,731 89,038,123 0.035061 31,777 1,114 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 273,222 5,676,944 0.048128 0 0 52.00

53.00 05300 ANESTHESIOLOGY 511,168 20,529,224 0.024900 5,245 131 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 1,254,660 24,482,787 0.051247 25,483 1,306 54.00

54.01 05401 ULTRASOUND 185,287 9,245,587 0.020041 19,600 393 54.01

54.03 05403 CARDIOVASCULAR LAB 1,548,955 30,674,383 0.050497 0 0 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 2,536,760 16,097,226 0.157590 0 0 55.00

55.01 05501 CHEMOTHERAPY 594,845 4,091,450 0.145387 0 0 55.01

56.01 05601 NUCLEAR MEDICINE 273,525 19,270,268 0.014194 1,550 22 56.01

57.00 05700 CT SCAN 1,127,280 41,420,556 0.027215 42,539 1,158 57.00

58.00 05800 MRI 625,989 18,091,357 0.034602 28,215 976 58.00

60.00 06000 LABORATORY 1,306,909 75,392,079 0.017335 237,005 4,108 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 59,258 5,778,105 0.010256 27,666 284 63.00

65.00 06500 RESPIRATORY THERAPY 421,144 19,000,932 0.022164 0 0 65.00

66.00 06600 PHYSICAL THERAPY 120,450 5,859,669 0.020556 1,074,624 22,090 66.00


66.02 06602 PHYSIATRY 0 0 0.000000 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 29,703 2,025,572 0.014664 915,689 13,428 67.00

68.00 06800 SPEECH PATHOLOGY 16,585 1,637,869 0.010126 492,401 4,986 68.00

69.01 06901 CV DIAGNOSTIC 219,030 25,275,144 0.008666 16,682 145 69.01


70.01 07001 NEUROPHYSIOLOGY 263,619 17,135,959 0.015384 194,675 2,995 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 560,974 87,352,621 0.006422 0 0 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 1,214,779 76,947,713 0.015787 0 0 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 1,536,566 114,961,515 0.013366 377,303 5,043 73.00

76.00 03950 CARDIAC REHAB 0 0 0.000000 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 101,048 734,782 0.137521 0 0 76.97


76.99 07699 LITHOTRIPSY 0 0 0.000000 0 0 76.99






90.02 09002 DIABETES CENTER 138,954 100,130 1.387736 0 0 90.02

91.00 09100 EMERGENCY 1,173,426 39,466,693 0.029732 0 0 91.00

91.01 09101 G.I. LABORATORY 665,439 8,529,970 0.078012 16,480 1,286 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 0 10,171,932 0.000000 0 0 92.00

200.00 Total (lines 50-199) 21,432,025 791,876,002 3,506,934 59,465 200.00


MCRIF32 - 8.8.159.0 118 | Page


Date/Time Prepared:

Worksheet D

Part IV

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110



THROUGH COSTS


IRF

PPS


Anesthetist

Cost

Nursing

School


Medical

Education

Cost

Total Cost

(sum of col 1

through col.

4)

1.00 2.00 3.00 4.00 5.00


50.00 05000 OPERATING ROOM 0 57,034 0 0 57,034 50.00


53.00 05300 ANESTHESIOLOGY 0 0 0 0 0 53.00


54.01 05401 ULTRASOUND 0 0 0 0 0 54.01



55.01 05501 CHEMOTHERAPY 0 0 0 0 0 55.01


57.00 05700 CT SCAN 0 0 0 0 0 57.00

58.00 05800 MRI 0 0 0 0 0 58.00

60.00 06000 LABORATORY 0 78,644 0 0 78,644 60.00






66.02 06602 PHYSIATRY 0 0 0 0 0 66.02



69.01 06901 CV DIAGNOSTIC 0 0 0 0 0 69.01






76.00 03950 CARDIAC REHAB 0 0 0 0 0 76.00



76.99 07699 LITHOTRIPSY 0 0 0 0 0 76.99






90.02 09002 DIABETES CENTER 0 0 0 0 0 90.02

91.00 09100 EMERGENCY 0 45,689 0 0 45,689 91.00

91.01 09101 G.I. LABORATORY 0 0 0 0 0 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 0 0 0 0 0 92.00

200.00 Total (lines 50-199) 0 301,648 0 0 301,648 200.00


MCRIF32 - 8.8.159.0 119 | Page


Date/Time Prepared:

Worksheet D

Part IV

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110



THROUGH COSTS


IRF

PPS


Outpatient

Cost (sum of

col. 2, 3 and

4)

Total Charges

(from Wkst.

C, Part I,

col. 8)

Ratio of Cost

to Charges

(col. 5 ÷

col. 7)

Outpatient

Ratio of Cost

to Charges

(col. 6 ÷

col. 7)

Inpatient

Program

Charges

6.00 7.00 8.00 9.00 10.00


50.00 05000 OPERATING ROOM 57,034 89,038,123 0.000641 0.000641 31,777 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0 5,676,944 0.000000 0.000000 0 52.00

53.00 05300 ANESTHESIOLOGY 0 20,529,224 0.000000 0.000000 5,245 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 113,889 24,482,787 0.004652 0.004652 25,483 54.00

54.01 05401 ULTRASOUND 0 9,245,587 0.000000 0.000000 19,600 54.01

54.03 05403 CARDIOVASCULAR LAB 6,392 30,674,383 0.000208 0.000208 0 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0 16,097,226 0.000000 0.000000 0 55.00

55.01 05501 CHEMOTHERAPY 0 4,091,450 0.000000 0.000000 0 55.01

56.01 05601 NUCLEAR MEDICINE 0 19,270,268 0.000000 0.000000 1,550 56.01

57.00 05700 CT SCAN 0 41,420,556 0.000000 0.000000 42,539 57.00

58.00 05800 MRI 0 18,091,357 0.000000 0.000000 28,215 58.00

60.00 06000 LABORATORY 78,644 75,392,079 0.001043 0.001043 237,005 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0 5,778,105 0.000000 0.000000 27,666 63.00

65.00 06500 RESPIRATORY THERAPY 0 19,000,932 0.000000 0.000000 0 65.00

66.00 06600 PHYSICAL THERAPY 0 5,859,669 0.000000 0.000000 1,074,624 66.00


66.02 06602 PHYSIATRY 0 0 0.000000 0.000000 0 66.02



69.01 06901 CV DIAGNOSTIC 0 25,275,144 0.000000 0.000000 16,682 69.01


70.01 07001 NEUROPHYSIOLOGY 0 17,135,959 0.000000 0.000000 194,675 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 0 87,352,621 0.000000 0.000000 0 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0 76,947,713 0.000000 0.000000 0 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 0 114,961,515 0.000000 0.000000 377,303 73.00

76.00 03950 CARDIAC REHAB 0 0 0.000000 0.000000 0 76.00

76.97 07697 CARDIAC REHABILITATION 0 734,782 0.000000 0.000000 0 76.97


76.99 07699 LITHOTRIPSY 0 0 0.000000 0.000000 0 76.99






90.02 09002 DIABETES CENTER 0 100,130 0.000000 0.000000 0 90.02

91.00 09100 EMERGENCY 45,689 39,466,693 0.001158 0.001158 0 91.00

91.01 09101 G.I. LABORATORY 0 8,529,970 0.000000 0.000000 16,480 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 0 10,171,932 0.000000 0.000000 0 92.00

200.00 Total (lines 50-199) 301,648 791,876,002 3,506,934 200.00


MCRIF32 - 8.8.159.0 120 | Page


Date/Time Prepared:

Worksheet D

Part IV

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110



THROUGH COSTS


IRF

PPS


Program

Pass-Through

Costs (col. 8

x col. 10)

Outpatient

Program

Charges

Outpatient

Program

Pass-Through

Costs (col. 9

x col. 12)

11.00 12.00 13.00


50.00 05000 OPERATING ROOM 20 0 0 50.00


53.00 05300 ANESTHESIOLOGY 0 0 0 53.00


54.01 05401 ULTRASOUND 0 0 0 54.01



55.01 05501 CHEMOTHERAPY 0 0 0 55.01


57.00 05700 CT SCAN 0 0 0 57.00

58.00 05800 MRI 0 0 0 58.00

60.00 06000 LABORATORY 247 0 0 60.00






66.02 06602 PHYSIATRY 0 0 0 66.02



69.01 06901 CV DIAGNOSTIC 0 0 0 69.01





73.00 07300 DRUGS CHARGED TO PATIENTS 0 1,275 0 73.00

76.00 03950 CARDIAC REHAB 0 0 0 76.00



76.99 07699 LITHOTRIPSY 0 0 0 76.99






90.02 09002 DIABETES CENTER 0 0 0 90.02

91.00 09100 EMERGENCY 0 0 0 91.00

91.01 09101 G.I. LABORATORY 0 0 0 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 0 0 0 92.00

200.00 Total (lines 50-199) 386 1,625 2 200.00


MCRIF32 - 8.8.159.0 121 | Page


Date/Time Prepared:

Worksheet D

Part V

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110




IRF

PPS

Charges Costs


Charge Ratio

From

Worksheet C,

Part I, col.

9

PPS

Reimbursed

Services (see

inst.)

Cost

Reimbursed

Services

Subject To

Ded. & Coins.

(see inst.)

Cost

Reimbursed

Services Not

Subject To

Ded. & Coins.

(see inst.)

PPS Services

(see inst.)

1.00 2.00 3.00 4.00 5.00


50.00 05000 OPERATING ROOM 0.175049 0 0 0 0 50.00


53.00 05300 ANESTHESIOLOGY 0.079455 0 0 0 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0.262369 350 0 0 92 54.00

54.01 05401 ULTRASOUND 0.122875 0 0 0 0 54.01

54.03 05403 CARDIOVASCULAR LAB 0.212884 0 0 0 0 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0.398830 0 0 0 0 55.00

55.01 05501 CHEMOTHERAPY 0.516072 0 0 0 0 55.01

56.01 05601 NUCLEAR MEDICINE 0.117403 0 0 0 0 56.01

57.00 05700 CT SCAN 0.074179 0 0 0 0 57.00

58.00 05800 MRI 0.094771 0 0 0 0 58.00

60.00 06000 LABORATORY 0.177083 0 0 0 0 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0.206623 0 0 0 0 63.00

65.00 06500 RESPIRATORY THERAPY 0.188867 0 0 0 0 65.00

66.00 06600 PHYSICAL THERAPY 0.241650 0 0 0 0 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0.305163 0 0 0 0 66.01

66.02 06602 PHYSIATRY 0.000000 0 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 0.182238 0 0 0 0 67.00

68.00 06800 SPEECH PATHOLOGY 0.157783 0 0 0 0 68.00

69.01 06901 CV DIAGNOSTIC 0.090070 0 0 0 0 69.01


70.01 07001 NEUROPHYSIOLOGY 0.081552 0 0 0 0 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 0.164812 0 0 0 0 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0.305228 0 0 0 0 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 0.215459 1,275 0 0 275 73.00

76.00 03950 CARDIAC REHAB 0.000000 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 0.892544 0 0 0 0 76.97


76.99 07699 LITHOTRIPSY 0.000000 0 0 0 0 76.99





90.01 09001 HYPERBARIC WOUND CLINIC 0.196285 0 0 0 0 90.01

90.02 09002 DIABETES CENTER 5.378418 0 0 0 0 90.02

91.00 09100 EMERGENCY 0.211285 0 0 0 0 91.00

91.01 09101 G.I. LABORATORY 0.230491 0 0 0 0 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 0.408588 0 0 0 0 92.00

200.00 Subtotal (see instructions) 1,625 0 0 367 200.00


Only Charges

0 0 201.00

202.00 Net Charges (line 200 +/- line 201) 1,625 0 0 367 202.00


MCRIF32 - 8.8.159.0 122 | Page


Date/Time Prepared:

Worksheet D

Part V

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110




IRF

PPS

Costs


Reimbursed

Services

Subject To

Ded. & Coins.

(see inst.)

Cost

Reimbursed

Services Not

Subject To

Ded. & Coins.

(see inst.)

6.00 7.00


50.00 05000 OPERATING ROOM 0 0 50.00


53.00 05300 ANESTHESIOLOGY 0 0 53.00


54.01 05401 ULTRASOUND 0 0 54.01



55.01 05501 CHEMOTHERAPY 0 0 55.01


57.00 05700 CT SCAN 0 0 57.00

58.00 05800 MRI 0 0 58.00

60.00 06000 LABORATORY 0 0 60.00






66.02 06602 PHYSIATRY 0 0 66.02



69.01 06901 CV DIAGNOSTIC 0 0 69.01





73.00 07300 DRUGS CHARGED TO PATIENTS 0 0 73.00

76.00 03950 CARDIAC REHAB 0 0 76.00



76.99 07699 LITHOTRIPSY 0 0 76.99






90.02 09002 DIABETES CENTER 0 0 90.02

91.00 09100 EMERGENCY 0 0 91.00

91.01 09101 G.I. LABORATORY 0 0 91.01


200.00 Subtotal (see instructions) 0 0 200.00


Only Charges

0 201.00

202.00 Net Charges (line 200 +/- line 201) 0 0 202.00


MCRIF32 - 8.8.159.0 123 | Page


Date/Time Prepared:

Worksheet D

Part V

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



Charges Costs


Charge Ratio

From

Worksheet C,

Part I, col.

9

PPS

Reimbursed

Services (see

inst.)

Cost

Reimbursed

Services

Subject To

Ded. & Coins.

(see inst.)

Cost

Reimbursed

Services Not

Subject To

Ded. & Coins.

(see inst.)

PPS Services

(see inst.)

1.00 2.00 3.00 4.00 5.00


50.00 05000 OPERATING ROOM 0.175049 0 9,019,336 0 0 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0.394335 0 434,405 0 0 52.00

53.00 05300 ANESTHESIOLOGY 0.079455 0 2,272,599 0 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0.262369 0 1,786,010 0 0 54.00

54.01 05401 ULTRASOUND 0.122875 0 1,372,223 0 0 54.01

54.03 05403 CARDIOVASCULAR LAB 0.212884 0 1,679,051 0 0 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0.398830 0 393,478 0 0 55.00

55.01 05501 CHEMOTHERAPY 0.516072 0 213,875 0 0 55.01

56.01 05601 NUCLEAR MEDICINE 0.117403 0 1,007,651 0 0 56.01

57.00 05700 CT SCAN 0.074179 0 3,170,339 0 0 57.00

58.00 05800 MRI 0.094771 0 873,517 0 0 58.00

60.00 06000 LABORATORY 0.177083 0 6,921,513 0 0 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0.206623 0 87,199 0 0 63.00

65.00 06500 RESPIRATORY THERAPY 0.188867 0 536,335 0 0 65.00

66.00 06600 PHYSICAL THERAPY 0.241650 0 13,077 0 0 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0.305163 0 2,690,678 0 0 66.01

66.02 06602 PHYSIATRY 0.000000 0 0 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 0.182238 0 3,489 0 0 67.00

68.00 06800 SPEECH PATHOLOGY 0.157783 0 8,972 0 0 68.00

69.01 06901 CV DIAGNOSTIC 0.090070 0 1,447,943 0 0 69.01


70.01 07001 NEUROPHYSIOLOGY 0.081552 0 789,914 0 0 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 0.164812 0 4,946,618 0 0 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0.305228 0 2,028,396 0 0 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 0.215459 0 8,494,925 0 0 73.00

76.00 03950 CARDIAC REHAB 0.000000 0 0 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 0.892544 0 42,104 0 0 76.97


76.99 07699 LITHOTRIPSY 0.000000 0 0 0 0 76.99





90.01 09001 HYPERBARIC WOUND CLINIC 0.196285 0 300,191 0 0 90.01

90.02 09002 DIABETES CENTER 5.378418 0 10,664 0 0 90.02

91.00 09100 EMERGENCY 0.211285 0 7,882,775 0 0 91.00

91.01 09101 G.I. LABORATORY 0.230491 0 671,094 0 0 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 0.408588 0 1,441,456 0 0 92.00

200.00 Subtotal (see instructions) 0 60,539,827 0 0 200.00


Only Charges

0 0 201.00

202.00 Net Charges (line 200 +/- line 201) 0 60,539,827 0 0 202.00


MCRIF32 - 8.8.159.0 124 | Page


Date/Time Prepared:

Worksheet D

Part V

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



Costs


Reimbursed

Services

Subject To

Ded. & Coins.

(see inst.)

Cost

Reimbursed

Services Not

Subject To

Ded. & Coins.

(see inst.)

6.00 7.00


50.00 05000 OPERATING ROOM 1,578,826 0 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 171,301 0 52.00

53.00 05300 ANESTHESIOLOGY 180,569 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 468,594 0 54.00

54.01 05401 ULTRASOUND 168,612 0 54.01

54.03 05403 CARDIOVASCULAR LAB 357,443 0 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 156,931 0 55.00

55.01 05501 CHEMOTHERAPY 110,375 0 55.01

56.01 05601 NUCLEAR MEDICINE 118,301 0 56.01

57.00 05700 CT SCAN 235,173 0 57.00

58.00 05800 MRI 82,784 0 58.00

60.00 06000 LABORATORY 1,225,682 0 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 18,017 0 63.00

65.00 06500 RESPIRATORY THERAPY 101,296 0 65.00

66.00 06600 PHYSICAL THERAPY 3,160 0 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 821,095 0 66.01

66.02 06602 PHYSIATRY 0 0 66.02


68.00 06800 SPEECH PATHOLOGY 1,416 0 68.00

69.01 06901 CV DIAGNOSTIC 130,416 0 69.01


70.01 07001 NEUROPHYSIOLOGY 64,419 0 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 815,262 0 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 619,123 0 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 1,830,308 0 73.00

76.00 03950 CARDIAC REHAB 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 37,580 0 76.97


76.99 07699 LITHOTRIPSY 0 0 76.99





90.01 09001 HYPERBARIC WOUND CLINIC 58,923 0 90.01

90.02 09002 DIABETES CENTER 57,355 0 90.02

91.00 09100 EMERGENCY 1,665,512 0 91.00

91.01 09101 G.I. LABORATORY 154,681 0 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 588,962 0 92.00

200.00 Subtotal (see instructions) 11,822,752 0 200.00


Only Charges

0 201.00

202.00 Net Charges (line 200 +/- line 201) 11,822,752 0 202.00


MCRIF32 - 8.8.159.0 125 | Page


Date/Time Prepared:

Worksheet D-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110COMPUTATION OF INPATIENT OPERATING COST


Cost Center Description

1.00

PART I - ALL PROVIDER COMPONENTS

INPATIENT DAYS

1.00 Inpatient days (including private room days and swing-bed days, excluding newborn) 32,405 1.00

2.00 Inpatient days (including private room days, excluding swing-bed and newborn days) 32,405 2.00

3.00 Private room days (excluding swing-bed and observation bed days). If you have only private room days,

do not complete this line.

0 3.00

4.00 Semi-private room days (excluding swing-bed and observation bed days) 27,883 4.00

5.00 Total swing-bed SNF type inpatient days (including private room days) through December 31 of the cost

reporting period

0 5.00

6.00 Total swing-bed SNF type inpatient days (including private room days) after December 31 of the cost

reporting period (if calendar year, enter 0 on this line)

0 6.00

7.00 Total swing-bed NF type inpatient days (including private room days) through December 31 of the cost

reporting period

0 7.00

8.00 Total swing-bed NF type inpatient days (including private room days) after December 31 of the cost


0 8.00

9.00 Total inpatient days including private room days applicable to the Program (excluding swing-bed and

newborn days)

16,163 9.00

10.00 Swing-bed SNF type inpatient days applicable to title XVIII only (including private room days)

through December 31 of the cost reporting period (see instructions)

0 10.00

11.00 Swing-bed SNF type inpatient days applicable to title XVIII only (including private room days) after

December 31 of the cost reporting period (if calendar year, enter 0 on this line)

0 11.00

12.00 Swing-bed NF type inpatient days applicable to titles V or XIX only (including private room days)

through December 31 of the cost reporting period

0 12.00


after December 31 of the cost reporting period (if calendar year, enter 0 on this line)

0 13.00

14.00 Medically necessary private room days applicable to the Program (excluding swing-bed days) 0 14.00

15.00 Total nursery days (title V or XIX only) 0 15.00

16.00 Nursery days (title V or XIX only) 0 16.00

SWING BED ADJUSTMENT

17.00 Medicare rate for swing-bed SNF services applicable to services through December 31 of the cost

reporting period

0.00 17.00

18.00 Medicare rate for swing-bed SNF services applicable to services after December 31 of the cost

reporting period

0.00 18.00

19.00 Medicaid rate for swing-bed NF services applicable to services through December 31 of the cost

reporting period

0.00 19.00

20.00 Medicaid rate for swing-bed NF services applicable to services after December 31 of the cost

reporting period

0.00 20.00

21.00 Total general inpatient routine service cost (see instructions) 29,782,995 21.00

22.00 Swing-bed cost applicable to SNF type services through December 31 of the cost reporting period (line

5 x line 17)

0 22.00

23.00 Swing-bed cost applicable to SNF type services after December 31 of the cost reporting period (line 6

x line 18)

0 23.00

24.00 Swing-bed cost applicable to NF type services through December 31 of the cost reporting period (line

7 x line 19)

0 24.00

25.00 Swing-bed cost applicable to NF type services after December 31 of the cost reporting period (line 8

x line 20)

0 25.00

26.00 Total swing-bed cost (see instructions) 0 26.00

27.00 General inpatient routine service cost net of swing-bed cost (line 21 minus line 26) 29,782,995 27.00

PRIVATE ROOM DIFFERENTIAL ADJUSTMENT

28.00 General inpatient routine service charges (excluding swing-bed and observation bed charges) 0 28.00

29.00 Private room charges (excluding swing-bed charges) 0 29.00

30.00 Semi-private room charges (excluding swing-bed charges) 0 30.00

31.00 General inpatient routine service cost/charge ratio (line 27 ÷ line 28) 0.000000 31.00

32.00 Average private room per diem charge (line 29 ÷ line 3) 0.00 32.00

33.00 Average semi-private room per diem charge (line 30 ÷ line 4) 0.00 33.00

34.00 Average per diem private room charge differential (line 32 minus line 33)(see instructions) 0.00 34.00

35.00 Average per diem private room cost differential (line 34 x line 31) 0.00 35.00

36.00 Private room cost differential adjustment (line 3 x line 35) 0 36.00

37.00 General inpatient routine service cost net of swing-bed cost and private room cost differential (line

27 minus line 36)

29,782,995 37.00

PART II - HOSPITAL AND SUBPROVIDERS ONLY

PROGRAM INPATIENT OPERATING COST BEFORE PASS THROUGH COST ADJUSTMENTS

38.00 Adjusted general inpatient routine service cost per diem (see instructions) 919.09 38.00

39.00 Program general inpatient routine service cost (line 9 x line 38) 14,855,252 39.00

40.00 Medically necessary private room cost applicable to the Program (line 14 x line 35) 0 40.00

41.00 Total Program general inpatient routine service cost (line 39 + line 40) 14,855,252 41.00


MCRIF32 - 8.8.159.0 126 | Page


Date/Time Prepared:

Worksheet D-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015




Inpatient

Cost

Total

Inpatient

Days

Average Per

Diem (col. 1

÷ col. 2)

Program Days Program Cost

(col. 3 x

col. 4)

1.00 2.00 3.00 4.00 5.00

42.00 NURSERY (title V & XIX only) 0 0 0.00 0 0 42.00

Intensive Care Type Inpatient Hospital Units




45.01 ADULT SPECIAL CARE 4,394,201 2,666 1,648.24 1,492 2,459,174 45.01


46.01 CARDIOTHORACIC ICU 3,631,943 2,024 1,794.44 1,135 2,036,689 46.01



1.00

48.00 Program inpatient ancillary service cost (Wkst. D-3, col. 3, line 200) 36,799,535 48.00

49.00 Total Program inpatient costs (sum of lines 41 through 48)(see instructions) 56,150,650 49.00

PASS THROUGH COST ADJUSTMENTS

50.00 Pass through costs applicable to Program inpatient routine services (from Wkst. D, sum of Parts I and

III)

3,571,554 50.00

51.00 Pass through costs applicable to Program inpatient ancillary services (from Wkst. D, sum of Parts II

and IV)

4,188,279 51.00

52.00 Total Program excludable cost (sum of lines 50 and 51) 7,759,833 52.00

53.00 Total Program inpatient operating cost excluding capital related, non-physician anesthetist, and

medical education costs (line 49 minus line 52)

48,390,817 53.00

TARGET AMOUNT AND LIMIT COMPUTATION

54.00 Program discharges 0 54.00

55.00 Target amount per discharge 0.00 55.00

56.00 Target amount (line 54 x line 55) 0 56.00

57.00 Difference between adjusted inpatient operating cost and target amount (line 56 minus line 53) 0 57.00

58.00 Bonus payment (see instructions) 0 58.00

59.00 Lesser of lines 53/54 or 55 from the cost reporting period ending 1996, updated and compounded by the

market basket

0.00 59.00

60.00 Lesser of lines 53/54 or 55 from prior year cost report, updated by the market basket 0.00 60.00

61.00 If line 53/54 is less than the lower of lines 55, 59 or 60 enter the lesser of 50% of the amount by

which operating costs (line 53) are less than expected costs (lines 54 x 60), or 1% of the target

amount (line 56), otherwise enter zero (see instructions)

0 61.00

62.00 Relief payment (see instructions) 0 62.00

63.00 Allowable Inpatient cost plus incentive payment (see instructions) 0 63.00

PROGRAM INPATIENT ROUTINE SWING BED COST

64.00 Medicare swing-bed SNF inpatient routine costs through December 31 of the cost reporting period (See

instructions)(title XVIII only)

0 64.00

65.00 Medicare swing-bed SNF inpatient routine costs after December 31 of the cost reporting period (See


0 65.00

66.00 Total Medicare swing-bed SNF inpatient routine costs (line 64 plus line 65)(title XVIII only). For

CAH (see instructions)

0 66.00

67.00 Title V or XIX swing-bed NF inpatient routine costs through December 31 of the cost reporting period

(line 12 x line 19)

0 67.00

68.00 Title V or XIX swing-bed NF inpatient routine costs after December 31 of the cost reporting period

(line 13 x line 20)

0 68.00

69.00 Total title V or XIX swing-bed NF inpatient routine costs (line 67 + line 68) 0 69.00

PART III - SKILLED NURSING FACILITY, OTHER NURSING FACILITY, AND ICF/IID ONLY

70.00 Skilled nursing facility/other nursing facility/ICF/IID routine service cost (line 37) 70.00

71.00 Adjusted general inpatient routine service cost per diem (line 70 ÷ line 2) 71.00

72.00 Program routine service cost (line 9 x line 71) 72.00

73.00 Medically necessary private room cost applicable to Program (line 14 x line 35) 73.00

74.00 Total Program general inpatient routine service costs (line 72 + line 73) 74.00

75.00 Capital-related cost allocated to inpatient routine service costs (from Worksheet B, Part II, column

26, line 45)

75.00

76.00 Per diem capital-related costs (line 75 ÷ line 2) 76.00

77.00 Program capital-related costs (line 9 x line 76) 77.00

78.00 Inpatient routine service cost (line 74 minus line 77) 78.00

79.00 Aggregate charges to beneficiaries for excess costs (from provider records) 79.00

80.00 Total Program routine service costs for comparison to the cost limitation (line 78 minus line 79) 80.00

81.00 Inpatient routine service cost per diem limitation 81.00

82.00 Inpatient routine service cost limitation (line 9 x line 81) 82.00

83.00 Reasonable inpatient routine service costs (see instructions) 83.00

84.00 Program inpatient ancillary services (see instructions) 84.00

85.00 Utilization review - physician compensation (see instructions) 85.00

86.00 Total Program inpatient operating costs (sum of lines 83 through 85) 86.00

PART IV - COMPUTATION OF OBSERVATION BED PASS THROUGH COST

87.00 Total observation bed days (see instructions) 4,522 87.00

88.00 Adjusted general inpatient routine cost per diem (line 27 ÷ line 2) 919.09 88.00

89.00 Observation bed cost (line 87 x line 88) (see instructions) 4,156,125 89.00


MCRIF32 - 8.8.159.0 127 | Page


Date/Time Prepared:

Worksheet D-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



Cost Center Description Cost Routine Cost

(from line

27)

column 1 ÷

column 2

Total

Observation

Bed Cost

(from line

89)

Observation

Bed Pass

Through Cost

(col. 3 x

col. 4) (see

instructions)

1.00 2.00 3.00 4.00 5.00

COMPUTATION OF OBSERVATION BED PASS THROUGH COST

90.00 Capital-related cost 4,790,998 29,782,995 0.160864 4,156,125 668,571 90.00

91.00 Nursing School cost 660,621 29,782,995 0.022181 4,156,125 92,187 91.00

92.00 Allied health cost 0 29,782,995 0.000000 4,156,125 0 92.00

93.00 All other Medical Education 0 29,782,995 0.000000 4,156,125 0 93.00


MCRIF32 - 8.8.159.0 128 | Page


Date/Time Prepared:

Worksheet D-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110


COMPUTATION OF INPATIENT OPERATING COST


IPF

PPS


1.00


INPATIENT DAYS





0 3.00



reporting period

0 5.00



0 6.00


reporting period

0 7.00



0 8.00


newborn days)

936 9.00



0 10.00



0 11.00



0 12.00



0 13.00






reporting period

0.00 17.00


reporting period

0.00 18.00


reporting period

0.00 19.00


reporting period

0.00 20.00



5 x line 17)

0 22.00


x line 18)

0 23.00


7 x line 19)

0 24.00


x line 20)

0 25.00














27 minus line 36)

2,351,542 37.00




39.00 Program general inpatient routine service cost (line 9 x line 38) 751,720 39.00


41.00 Total Program general inpatient routine service cost (line 39 + line 40) 751,720 41.00


MCRIF32 - 8.8.159.0 129 | Page


Date/Time Prepared:

Worksheet D-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110




IPF

PPS


Inpatient

Cost

Total

Inpatient

Days

Average Per

Diem (col. 1

÷ col. 2)


(col. 3 x

col. 4)

1.00 2.00 3.00 4.00 5.00






45.01 ADULT SPECIAL CARE 0 0 0.00 0 0 45.01


46.01 CARDIOTHORACIC ICU 0 0 0.00 0 0 46.01



1.00

48.00 Program inpatient ancillary service cost (Wkst. D-3, col. 3, line 200) 156,918 48.00

49.00 Total Program inpatient costs (sum of lines 41 through 48)(see instructions) 908,638 49.00



III)

132,145 50.00


and IV)

12,990 51.00

52.00 Total Program excludable cost (sum of lines 50 and 51) 145,135 52.00



763,503 53.00








market basket

0.00 59.00





0 61.00






0 64.00



0 65.00



0 66.00


(line 12 x line 19)

0 67.00


(line 13 x line 20)

0 68.00









26, line 45)

75.00













87.00 Total observation bed days (see instructions) 0 87.00


89.00 Observation bed cost (line 87 x line 88) (see instructions) 0 89.00


MCRIF32 - 8.8.159.0 130 | Page


Date/Time Prepared:

Worksheet D-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110




IPF

PPS


(from line

27)

column 1 ÷

column 2

Total

Observation

Bed Cost

(from line

89)

Observation

Bed Pass

Through Cost

(col. 3 x

col. 4) (see

instructions)

1.00 2.00 3.00 4.00 5.00


90.00 Capital-related cost 346,718 2,351,542 0.147443 0 0 90.00

91.00 Nursing School cost 66,664 2,351,542 0.028349 0 0 91.00

92.00 Allied health cost 0 2,351,542 0.000000 0 0 92.00

93.00 All other Medical Education 0 2,351,542 0.000000 0 0 93.00


MCRIF32 - 8.8.159.0 131 | Page


Date/Time Prepared:

Worksheet D-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110




IRF

PPS


1.00


INPATIENT DAYS





0 3.00



reporting period

0 5.00



0 6.00


reporting period

0 7.00



0 8.00


newborn days)

1,615 9.00



0 10.00



0 11.00



0 12.00



0 13.00






reporting period

0.00 17.00


reporting period

0.00 18.00


reporting period

0.00 19.00


reporting period

0.00 20.00



5 x line 17)

0 22.00


x line 18)

0 23.00


7 x line 19)

0 24.00


x line 20)

0 25.00














27 minus line 36)

2,299,362 37.00








MCRIF32 - 8.8.159.0 132 | Page


Date/Time Prepared:

Worksheet D-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110




IRF

PPS


Inpatient

Cost

Total

Inpatient

Days

Average Per

Diem (col. 1

÷ col. 2)


(col. 3 x

col. 4)

1.00 2.00 3.00 4.00 5.00











1.00





III)

293,833 50.00


and IV)

59,851 51.00

52.00 Total Program excludable cost (sum of lines 50 and 51) 353,684 52.00



1,903,360 53.00








market basket

0.00 59.00





0 61.00






0 64.00



0 65.00



0 66.00


(line 12 x line 19)

0 67.00


(line 13 x line 20)

0 68.00









26, line 45)

75.00

















MCRIF32 - 8.8.159.0 133 | Page


Date/Time Prepared:

Worksheet D-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110




IRF

PPS


(from line

27)

column 1 ÷

column 2

Total

Observation

Bed Cost

(from line

89)

Observation

Bed Pass

Through Cost

(col. 3 x

col. 4) (see

instructions)

1.00 2.00 3.00 4.00 5.00



91.00 Nursing School cost 49,477 2,299,362 0.021518 0 0 91.00




MCRIF32 - 8.8.159.0 134 | Page


Date/Time Prepared:

Worksheet D-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015




1.00


INPATIENT DAYS





0 3.00



reporting period

0 5.00



0 6.00


reporting period

0 7.00



0 8.00


newborn days)

2,898 9.00



0 10.00



0 11.00



0 12.00



0 13.00


15.00 Total nursery days (title V or XIX only) 2,858 15.00

16.00 Nursery days (title V or XIX only) 1,199 16.00



reporting period

0.00 17.00


reporting period

0.00 18.00


reporting period

0.00 19.00


reporting period

0.00 20.00



5 x line 17)

0 22.00


x line 18)

0 23.00


7 x line 19)

0 24.00


x line 20)

0 25.00














27 minus line 36)

29,782,995 37.00








MCRIF32 - 8.8.159.0 135 | Page


Date/Time Prepared:

Worksheet D-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015




Inpatient

Cost

Total

Inpatient

Days

Average Per

Diem (col. 1

÷ col. 2)


(col. 3 x

col. 4)

1.00 2.00 3.00 4.00 5.00

42.00 NURSERY (title V & XIX only) 1,245,738 2,858 435.88 1,199 522,620 42.00





45.01 ADULT SPECIAL CARE 4,394,201 2,666 1,648.24 352 580,180 45.01


46.01 CARDIOTHORACIC ICU 3,631,943 2,024 1,794.44 136 244,044 46.01



1.00

48.00 Program inpatient ancillary service cost (Wkst. D-3, col. 3, line 200) 3,307,925 48.00




III)

0 50.00


and IV)

0 51.00

52.00 Total Program excludable cost (sum of lines 50 and 51) 0 52.00



0 53.00








market basket

0.00 59.00





0 61.00






0 64.00



0 65.00



0 66.00


(line 12 x line 19)

0 67.00


(line 13 x line 20)

0 68.00









26, line 45)

75.00













87.00 Total observation bed days (see instructions) 4,522 87.00


89.00 Observation bed cost (line 87 x line 88) (see instructions) 4,156,125 89.00


MCRIF32 - 8.8.159.0 136 | Page


Date/Time Prepared:

Worksheet D-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015




(from line

27)

column 1 ÷

column 2

Total

Observation

Bed Cost

(from line

89)

Observation

Bed Pass

Through Cost

(col. 3 x

col. 4) (see

instructions)

1.00 2.00 3.00 4.00 5.00


90.00 Capital-related cost 4,790,998 29,782,995 0.160864 4,156,125 668,571 90.00

91.00 Nursing School cost 0 29,782,995 0.000000 4,156,125 0 91.00

92.00 Allied health cost 0 29,782,995 0.000000 4,156,125 0 92.00

93.00 All other Medical Education 0 29,782,995 0.000000 4,156,125 0 93.00


MCRIF32 - 8.8.159.0 137 | Page


Date/Time Prepared:

Worksheet D-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110



Title XIX Subprovider -

IPF

Cost


1.00


INPATIENT DAYS





0 3.00



reporting period

0 5.00



0 6.00


reporting period

0 7.00



0 8.00


newborn days)

785 9.00



0 10.00



0 11.00



0 12.00



0 13.00






reporting period

0.00 17.00


reporting period

0.00 18.00


reporting period

0.00 19.00


reporting period

0.00 20.00



5 x line 17)

0 22.00


x line 18)

0 23.00


7 x line 19)

0 24.00


x line 20)

0 25.00














27 minus line 36)

2,351,542 37.00








MCRIF32 - 8.8.159.0 138 | Page


Date/Time Prepared:

Worksheet D-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110




IPF

Cost


Inpatient

Cost

Total

Inpatient

Days

Average Per

Diem (col. 1

÷ col. 2)


(col. 3 x

col. 4)

1.00 2.00 3.00 4.00 5.00











1.00





III)

0 50.00


and IV)

0 51.00




0 53.00








market basket

0.00 59.00





0 61.00






0 64.00



0 65.00



0 66.00


(line 12 x line 19)

0 67.00


(line 13 x line 20)

0 68.00









26, line 45)

75.00

















MCRIF32 - 8.8.159.0 139 | Page


Date/Time Prepared:

Worksheet D-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110




IPF

Cost


(from line

27)

column 1 ÷

column 2

Total

Observation

Bed Cost

(from line

89)

Observation

Bed Pass

Through Cost

(col. 3 x

col. 4) (see

instructions)

1.00 2.00 3.00 4.00 5.00



91.00 Nursing School cost 0 2,351,542 0.000000 0 0 91.00




MCRIF32 - 8.8.159.0 140 | Page


Date/Time Prepared:

Worksheet D-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110




IRF

Cost


1.00


INPATIENT DAYS





0 3.00



reporting period

0 5.00



0 6.00


reporting period

0 7.00



0 8.00


newborn days)

153 9.00



0 10.00



0 11.00



0 12.00



0 13.00






reporting period

0.00 17.00


reporting period

0.00 18.00


reporting period

0.00 19.00


reporting period

0.00 20.00



5 x line 17)

0 22.00


x line 18)

0 23.00


7 x line 19)

0 24.00


x line 20)

0 25.00














27 minus line 36)

2,299,362 37.00








MCRIF32 - 8.8.159.0 141 | Page


Date/Time Prepared:

Worksheet D-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110




IRF

Cost


Inpatient

Cost

Total

Inpatient

Days

Average Per

Diem (col. 1

÷ col. 2)


(col. 3 x

col. 4)

1.00 2.00 3.00 4.00 5.00











1.00





III)

0 50.00


and IV)

0 51.00




0 53.00








market basket

0.00 59.00





0 61.00






0 64.00



0 65.00



0 66.00


(line 12 x line 19)

0 67.00


(line 13 x line 20)

0 68.00









26, line 45)

75.00

















MCRIF32 - 8.8.159.0 142 | Page


Date/Time Prepared:

Worksheet D-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110




IRF

Cost


(from line

27)

column 1 ÷

column 2

Total

Observation

Bed Cost

(from line

89)

Observation

Bed Pass

Through Cost

(col. 3 x

col. 4) (see

instructions)

1.00 2.00 3.00 4.00 5.00



91.00 Nursing School cost 0 2,299,362 0.000000 0 0 91.00




MCRIF32 - 8.8.159.0 143 | Page


Date/Time Prepared:

Worksheet D-3

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110INPATIENT ANCILLARY SERVICE COST APPORTIONMENT


Cost Center Description Ratio of Cost

To Charges

Inpatient

Program

Charges

Inpatient

Program Costs

(col. 1 x

col. 2)

1.00 2.00 3.00


30.00 03000 ADULTS & PEDIATRICS 12,048,640 30.00

33.01 03301 ADULT SPECIAL CARE 2,616,403 33.01

34.01 03401 CARDIOTHORACIC ICU 1,560,625 34.01

40.00 04000 SUBPROVIDER - IPF 108,488 40.00

41.00 04100 SUBPROVIDER - IRF 0 41.00

43.00 04300 NURSERY 43.00


50.00 05000 OPERATING ROOM 0.175049 27,656,867 4,841,307 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0.394335 9,052 3,570 52.00

53.00 05300 ANESTHESIOLOGY 0.079455 5,778,020 459,093 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0.262369 5,162,270 1,354,420 54.00

54.01 05401 ULTRASOUND 0.122875 1,405,967 172,758 54.01

54.03 05403 CARDIOVASCULAR LAB 0.212884 6,910,180 1,471,067 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0.398830 386,879 154,299 55.00

55.01 05501 CHEMOTHERAPY 0.516072 10,156 5,241 55.01

56.01 05601 NUCLEAR MEDICINE 0.117403 1,053,229 123,652 56.01

57.00 05700 CT SCAN 0.074179 6,226,318 461,862 57.00

58.00 05800 MRI 0.094771 1,755,001 166,323 58.00

60.00 06000 LABORATORY 0.177083 20,507,116 3,631,462 60.00

62.30 06250 BLOOD CLOTTING FACTORS FOR HEMOPH. 0.000000 0 0 62.30

63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0.206623 3,322,670 686,540 63.00

65.00 06500 RESPIRATORY THERAPY 0.188867 9,492,256 1,792,774 65.00

66.00 06600 PHYSICAL THERAPY 0.241650 2,714,944 656,066 66.00

66.01 06601 SOUTHEAST OUTPATIENT REHAB 0.305163 0 0 66.01

66.02 06602 PHYSIATRY 0.000000 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 0.182238 455,893 83,081 67.00

68.00 06800 SPEECH PATHOLOGY 0.157783 600,112 94,687 68.00

69.01 06901 CV DIAGNOSTIC 0.090070 4,442,839 400,167 69.01

69.02 06902 ELECTROPHYSIOLOGY LAB 0.000000 0 0 69.02

70.01 07001 NEUROPHYSIOLOGY 0.081552 4,482,768 365,579 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 0.164812 24,864,691 4,097,999 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0.305228 27,152,313 8,287,646 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 0.215459 25,815,579 5,562,199 73.00

76.00 03950 CARDIAC REHAB 0.000000 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 0.892544 5,241 4,678 76.97

76.98 07698 HYPERBARIC OXYGEN THERAPY 0.000000 0 0 76.98

76.99 07699 LITHOTRIPSY 0.000000 0 0 76.99





90.01 09001 HYPERBARIC WOUND CLINIC 0.196285 0 0 90.01

90.02 09002 DIABETES CENTER 5.378418 0 0 90.02

91.00 09100 EMERGENCY 0.211285 5,210,873 1,100,979 91.00

91.01 09101 G.I. LABORATORY 0.230491 1,087,125 250,573 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 0.408588 1,398,751 571,513 92.00

200.00 Total (sum of lines 50-94 and 96-98) 187,907,110 36,799,535 200.00

201.00 Less PBP Clinic Laboratory Services-Program only charges (line 61) 0 201.00

202.00 Net Charges (line 200 minus line 201) 187,907,110 202.00


MCRIF32 - 8.8.159.0 144 | Page


Date/Time Prepared:

Worksheet D-3

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110


INPATIENT ANCILLARY SERVICE COST APPORTIONMENT


IPF

PPS


To Charges

Inpatient

Program

Charges

Inpatient

Program Costs

(col. 1 x

col. 2)

1.00 2.00 3.00





40.00 04000 SUBPROVIDER - IPF 606,616 40.00

41.00 04100 SUBPROVIDER - IRF 0 41.00

43.00 04300 NURSERY 43.00


50.00 05000 OPERATING ROOM 0.175049 0 0 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0.394335 0 0 52.00

53.00 05300 ANESTHESIOLOGY 0.079455 0 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0.262369 5,476 1,437 54.00

54.01 05401 ULTRASOUND 0.122875 13,036 1,602 54.01

54.03 05403 CARDIOVASCULAR LAB 0.212884 0 0 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0.398830 0 0 55.00

55.01 05501 CHEMOTHERAPY 0.516072 0 0 55.01

56.01 05601 NUCLEAR MEDICINE 0.117403 0 0 56.01

57.00 05700 CT SCAN 0.074179 15,174 1,126 57.00

58.00 05800 MRI 0.094771 6,923 656 58.00

60.00 06000 LABORATORY 0.177083 192,020 34,003 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0.206623 0 0 63.00

65.00 06500 RESPIRATORY THERAPY 0.188867 65,853 12,437 65.00

66.00 06600 PHYSICAL THERAPY 0.241650 37,884 9,155 66.00


66.02 06602 PHYSIATRY 0.000000 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 0.182238 1,462 266 67.00


69.01 06901 CV DIAGNOSTIC 0.090070 2,230 201 69.01


70.01 07001 NEUROPHYSIOLOGY 0.081552 0 0 70.01

71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 0.164812 0 0 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0.305228 0 0 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 0.215459 436,679 94,086 73.00

76.00 03950 CARDIAC REHAB 0.000000 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 0.892544 0 0 76.97


76.99 07699 LITHOTRIPSY 0.000000 0 0 76.99






90.02 09002 DIABETES CENTER 5.378418 0 0 90.02

91.00 09100 EMERGENCY 0.211285 0 0 91.00

91.01 09101 G.I. LABORATORY 0.230491 0 0 91.01

92.00 09200 OBSERVATION BEDS (NON-DISTINCT PART 0.408588 0 0 92.00

200.00 Total (sum of lines 50-94 and 96-98) 789,092 156,918 200.00


202.00 Net Charges (line 200 minus line 201) 789,092 202.00


MCRIF32 - 8.8.159.0 145 | Page


Date/Time Prepared:

Worksheet D-3

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110




IRF

PPS


To Charges

Inpatient

Program

Charges

Inpatient

Program Costs

(col. 1 x

col. 2)

1.00 2.00 3.00





40.00 04000 SUBPROVIDER - IPF 0 40.00

41.00 04100 SUBPROVIDER - IRF 960,925 41.00

43.00 04300 NURSERY 43.00


50.00 05000 OPERATING ROOM 0.175049 31,777 5,563 50.00


53.00 05300 ANESTHESIOLOGY 0.079455 5,245 417 53.00


54.01 05401 ULTRASOUND 0.122875 19,600 2,408 54.01



55.01 05501 CHEMOTHERAPY 0.516072 0 0 55.01

56.01 05601 NUCLEAR MEDICINE 0.117403 1,550 182 56.01

57.00 05700 CT SCAN 0.074179 42,539 3,156 57.00

58.00 05800 MRI 0.094771 28,215 2,674 58.00

60.00 06000 LABORATORY 0.177083 237,005 41,970 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0.206623 27,666 5,716 63.00

65.00 06500 RESPIRATORY THERAPY 0.188867 0 0 65.00

66.00 06600 PHYSICAL THERAPY 0.241650 1,074,624 259,683 66.00


66.02 06602 PHYSIATRY 0.000000 0 0 66.02



69.01 06901 CV DIAGNOSTIC 0.090070 16,682 1,503 69.01


70.01 07001 NEUROPHYSIOLOGY 0.081552 194,675 15,876 70.01




76.00 03950 CARDIAC REHAB 0.000000 0 0 76.00



76.99 07699 LITHOTRIPSY 0.000000 0 0 76.99






90.02 09002 DIABETES CENTER 5.378418 0 0 90.02

91.00 09100 EMERGENCY 0.211285 0 0 91.00

91.01 09101 G.I. LABORATORY 0.230491 16,480 3,798 91.01


200.00 Total (sum of lines 50-94 and 96-98) 3,506,934 675,491 200.00




MCRIF32 - 8.8.159.0 146 | Page


Date/Time Prepared:

Worksheet D-3

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110INPATIENT ANCILLARY SERVICE COST APPORTIONMENT



To Charges

Inpatient

Program

Charges

Inpatient

Program Costs

(col. 1 x

col. 2)

1.00 2.00 3.00


30.00 03000 ADULTS & PEDIATRICS 2,096,010 30.00

33.01 03301 ADULT SPECIAL CARE 795,586 33.01

34.01 03401 CARDIOTHORACIC ICU 232,363 34.01

40.00 04000 SUBPROVIDER - IPF 0 40.00

41.00 04100 SUBPROVIDER - IRF 0 41.00

43.00 04300 NURSERY 864,188 43.00


50.00 05000 OPERATING ROOM 0.175049 1,449,093 253,662 50.00

52.00 05200 DELIVERY ROOM & LABOR ROOM 0.394335 1,418,330 559,297 52.00

53.00 05300 ANESTHESIOLOGY 0.079455 395,393 31,416 53.00


54.01 05401 ULTRASOUND 0.122875 153,576 18,871 54.01

54.03 05403 CARDIOVASCULAR LAB 0.212884 434,833 92,569 54.03

55.00 05500 RADIOLOGY-THERAPEUTIC 0.398830 17,383 6,933 55.00

55.01 05501 CHEMOTHERAPY 0.516072 0 0 55.01

56.01 05601 NUCLEAR MEDICINE 0.117403 109,788 12,889 56.01

57.00 05700 CT SCAN 0.074179 336,939 24,994 57.00

58.00 05800 MRI 0.094771 148,365 14,061 58.00

60.00 06000 LABORATORY 0.177083 2,447,412 433,395 60.00



65.00 06500 RESPIRATORY THERAPY 0.188867 1,172,724 221,489 65.00



66.02 06602 PHYSIATRY 0.000000 0 0 66.02



69.01 06901 CV DIAGNOSTIC 0.090070 402,018 36,210 69.01



71.00 07100 MEDICAL SUPPLIES CHARGED TO PATIENT 0.164812 2,191,425 361,173 71.00

72.00 07200 IMPL. DEV. CHARGED TO PATIENTS 0.305228 793,512 242,202 72.00

73.00 07300 DRUGS CHARGED TO PATIENTS 0.215459 3,538,841 762,475 73.00

76.00 03950 CARDIAC REHAB 0.000000 0 0 76.00

76.97 07697 CARDIAC REHABILITATION 0.892544 2,023 1,806 76.97


76.99 07699 LITHOTRIPSY 0.000000 0 0 76.99


88.00 08800 RURAL HEALTH CLINIC 0.000000 0 0 88.00

88.01 08801 RURAL HEALTH CLINIC II 1.179530 0 0 88.01

88.02 08802 RURAL HEALTH CLINIC III 1.012348 0 0 88.02


90.02 09002 DIABETES CENTER 5.378418 0 0 90.02

91.00 09100 EMERGENCY 0.211285 0 0 91.00

91.01 09101 G.I. LABORATORY 0.230491 0 0 91.01


200.00 Total (sum of lines 50-94 and 96-98) 16,034,774 3,307,925 200.00




MCRIF32 - 8.8.159.0 147 | Page


Date/Time Prepared:

Worksheet D-3

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110




IPF

Cost


To Charges

Inpatient

Program

Charges

Inpatient

Program Costs

(col. 1 x

col. 2)

1.00 2.00 3.00





40.00 04000 SUBPROVIDER - IPF 707,687 40.00

41.00 04100 SUBPROVIDER - IRF 0 41.00

43.00 04300 NURSERY 0 43.00


50.00 05000 OPERATING ROOM 0.175049 0 0 50.00


53.00 05300 ANESTHESIOLOGY 0.079455 0 0 53.00


54.01 05401 ULTRASOUND 0.122875 873 107 54.01



55.01 05501 CHEMOTHERAPY 0.516072 0 0 55.01


57.00 05700 CT SCAN 0.074179 1,062 79 57.00

58.00 05800 MRI 0.094771 2,967 281 58.00

60.00 06000 LABORATORY 0.177083 51,975 9,204 60.00


63.00 06300 BLOOD STORING, PROCESSING & TRANS. 0.206623 0 0 63.00

65.00 06500 RESPIRATORY THERAPY 0.188867 21,890 4,134 65.00

66.00 06600 PHYSICAL THERAPY 0.241650 1,424 344 66.00


66.02 06602 PHYSIATRY 0.000000 0 0 66.02

67.00 06700 OCCUPATIONAL THERAPY 0.182238 456 83 67.00

68.00 06800 SPEECH PATHOLOGY 0.157783 0 0 68.00

69.01 06901 CV DIAGNOSTIC 0.090070 880 79 69.01


70.01 07001 NEUROPHYSIOLOGY 0.081552 0 0 70.01




76.00 03950 CARDIAC REHAB 0.000000 0 0 76.00



76.99 07699 LITHOTRIPSY 0.000000 0 0 76.99






90.02 09002 DIABETES CENTER 5.378418 0 0 90.02

91.00 09100 EMERGENCY 0.211285 0 0 91.00

91.01 09101 G.I. LABORATORY 0.230491 0 0 91.01






MCRIF32 - 8.8.159.0 148 | Page


Date/Time Prepared:

Worksheet D-3

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110




IRF

Cost


To Charges

Inpatient

Program

Charges

Inpatient

Program Costs

(col. 1 x

col. 2)

1.00 2.00 3.00





40.00 04000 SUBPROVIDER - IPF 0 40.00

41.00 04100 SUBPROVIDER - IRF 92,743 41.00

43.00 04300 NURSERY 0 43.00


50.00 05000 OPERATING ROOM 0.175049 0 0 50.00


53.00 05300 ANESTHESIOLOGY 0.079455 0 0 53.00

54.00 05400 RADIOLOGY-DIAGNOSTIC 0.262369 467 123 54.00

54.01 05401 ULTRASOUND 0.122875 500 61 54.01



55.01 05501 CHEMOTHERAPY 0.516072 0 0 55.01


57.00 05700 CT SCAN 0.074179 4,643 344 57.00

58.00 05800 MRI 0.094771 9,407 892 58.00

60.00 06000 LABORATORY 0.177083 18,505 3,277 60.00



65.00 06500 RESPIRATORY THERAPY 0.188867 0 0 65.00



66.02 06602 PHYSIATRY 0.000000 0 0 66.02



69.01 06901 CV DIAGNOSTIC 0.090070 0 0 69.01






76.00 03950 CARDIAC REHAB 0.000000 0 0 76.00



76.99 07699 LITHOTRIPSY 0.000000 0 0 76.99






90.02 09002 DIABETES CENTER 5.378418 0 0 90.02

91.00 09100 EMERGENCY 0.211285 0 0 91.00

91.01 09101 G.I. LABORATORY 0.230491 0 0 91.01






MCRIF32 - 8.8.159.0 149 | Page


Date/Time Prepared:

Worksheet E

Part A

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110CALCULATION OF REIMBURSEMENT SETTLEMENT


0 1.00 2.00

PART A - INPATIENT HOSPITAL SERVICES UNDER IPPS

1.00 DRG Amounts Other than Outlier Payments 0 1.00

1.01 DRG amounts other than outlier payments for discharges occurring prior

to October 1 (see instructions)

28,618,003 1.01

1.02 DRG amounts other than outlier payments for discharges occurring on or

after October 1 (see instructions)

8,366,433 1.02

1.03 DRG for federal specific operating payment for Model 4 BPCI for

discharges occurring prior to October 1 (see instructions)

0 1.03

1.04 DRG for federal specific operating payment for Model 4 BPCI for

discharges occurring on or after October 1 (see instructions)

0 1.04

2.00 Outlier payments for discharges. (see instructions) 3,107,252 2.00

2.01 Outlier reconciliation amount 0 2.01

2.02 Outlier payment for discharges for Model 4 BPCI (see instructions) 0 2.02

3.00 Managed Care Simulated Payments 4,971,270 3.00

4.00 Bed days available divided by number of days in the cost reporting

period (see instructions)

183.61 4.00

Indirect Medical Education Adjustment

5.00 FTE count for allopathic and osteopathic programs for the most recent

cost reporting period ending on or before 12/31/1996.(see instructions)

0.00 5.00

6.00 FTE count for allopathic and osteopathic programs which meet the

criteria for an add-on to the cap for new programs in accordance with 42

CFR 413.79(e)

0.00 6.00

7.00 MMA Section 422 reduction amount to the IME cap as specified under 42

CFR §412.105(f)(1)(iv)(B)(1)

0.00 7.00

7.01 ACA Section 5503 reduction amount to the IME cap as specified under 42

CFR §412.105(f)(1)(iv)(B)(2) If the cost report straddles July 1, 2011

then see instructions.

0.00 7.01

8.00 Adjustment (increase or decrease) to the FTE count for allopathic and

osteopathic programs for affiliated programs in accordance with 42 CFR

413.75(b), 413.79(c)(2)(iv), 64 FR 26340 (May 12, 1998), and 67 FR 50069

(August 1, 2002).

0.00 8.00

8.01 The amount of increase if the hospital was awarded FTE cap slots under

section 5503 of the ACA. If the cost report straddles July 1, 2011, see

instructions.

0.00 8.01

8.02 The amount of increase if the hospital was awarded FTE cap slots from a

closed teaching hospital under section 5506 of ACA. (see instructions)

0.00 8.02

9.00 Sum of lines 5 plus 6 minus lines (7 and 7.01) plus/minus lines (8, 8,01

and 8,02) (see instructions)

0.00 9.00

10.00 FTE count for allopathic and osteopathic programs in the current year

from your records

0.00 10.00

11.00 FTE count for residents in dental and podiatric programs. 0.00 11.00

12.00 Current year allowable FTE (see instructions) 0.00 12.00

13.00 Total allowable FTE count for the prior year. 0.00 13.00

14.00 Total allowable FTE count for the penultimate year if that year ended on

or after September 30, 1997, otherwise enter zero.

0.00 14.00

15.00 Sum of lines 12 through 14 divided by 3. 0.00 15.00

16.00 Adjustment for residents in initial years of the program 0.00 16.00

17.00 Adjustment for residents displaced by program or hospital closure 0.00 17.00

18.00 Adjusted rolling average FTE count 0.00 18.00

19.00 Current year resident to bed ratio (line 18 divided by line 4). 0.000000 19.00

20.00 Prior year resident to bed ratio (see instructions) 0.000000 20.00

21.00 Enter the lesser of lines 19 or 20 (see instructions) 0.000000 21.00

22.00 IME payment adjustment (see instructions) 0 22.00

22.01 IME payment adjustment - Managed Care (see instructions) 0 22.01

Indirect Medical Education Adjustment for the Add-on for Section 422 of the MMA

23.00 Number of additional allopathic and osteopathic IME FTE resident cap

slots under 42 Sec. 412.105 (f)(1)(iv)(C ).

0.00 23.00

24.00 IME FTE Resident Count Over Cap (see instructions) 0.00 24.00

25.00 If the amount on line 24 is greater than -0-, then enter the lower of

line 23 or line 24 (see instructions)

0.00 25.00

26.00 Resident to bed ratio (divide line 25 by line 4) 0.000000 26.00

27.00 IME payments adjustment factor. (see instructions) 0.000000 27.00

28.00 IME add-on adjustment amount (see instructions) 0 28.00

28.01 IME add-on adjustment amount - Managed Care (see instructions) 0 28.01

29.00 Total IME payment ( sum of lines 22 and 28) 0 29.00

29.01 Total IME payment - Managed Care (sum of lines 22.01 and 28.01) 0 29.01

Disproportionate Share Adjustment

30.00 Percentage of SSI recipient patient days to Medicare Part A patient days

(see instructions)

7.27 30.00

31.00 Percentage of Medicaid patient days (see instructions) 17.14 31.00

32.00 Sum of lines 30 and 31 24.41 32.00

33.00 Allowable disproportionate share percentage (see instructions) 9.35 33.00

34.00 Disproportionate share adjustment (see instructions) 864,511 34.00


MCRIF32 - 8.8.159.0 150 | Page


Date/Time Prepared:

Worksheet E

Part A

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



Prior to

October 1

On/After

October 1

0 1.00 2.00

Uncompensated Care Adjustment

35.00 Total uncompensated care amount (see instructions) 35.007,647,644,885 6,406,145,534

35.01 Factor 3 (see instructions) 35.010.000221765 0.000228236

35.02 Hospital uncompensated care payment (If line 34 is zero,

enter zero on this line) (see instructions)

35.021,695,977 1,462,113

35.03 Pro rata share of the hospital uncompensated care payment

amount (see instructions)

35.031,268,498 367,525

36.00 Total uncompensated care (sum of columns 1 and 2 on line

35.03)

36.001,636,023

Additional payment for high percentage of ESRD beneficiary discharges (lines 40 through 46)

40.00 Total Medicare discharges on Worksheet S-3, Part I

excluding discharges for MS-DRGs 652, 682, 683, 684 and

685 (see instructions)

40.000

41.00 Total ESRD Medicare discharges excluding MS-DRGs 652,

682, 683, 684 an 685. (see instructions)

41.000

41.01 Total ESRD Medicare covered and paid discharges excluding

MS-DRGs 652, 682, 683, 684 an 685. (see instructions)

41.010

42.00 Divide line 41 by line 40 (if less than 10%, you do not

qualify for adjustment)

42.000.00

43.00 Total Medicare ESRD inpatient days excluding MS-DRGs 652,

682, 683, 684 an 685. (see instructions)

43.000

44.00 Ratio of average length of stay to one week (line 43

divided by line 41 divided by 7 days)

44.000.000000

45.00 Average weekly cost for dialysis treatments (see

instructions)

45.000.00

46.00 Total additional payment (line 45 times line 44 times line

41.01)

46.000

47.00 Subtotal (see instructions) 47.0042,592,222

48.00 Hospital specific payments (to be completed by SCH and

MDH, small rural hospitals only.(see instructions)

48.000

49.00 Total payment for inpatient operating costs (see

instructions)

49.0042,592,222

50.00 Payment for inpatient program capital (from Wkst. L, Pt. I

and Pt. II, as applicable)

50.003,505,874

51.00 Exception payment for inpatient program capital (Wkst. L,

Pt. III, see instructions)

51.000

52.00 Direct graduate medical education payment (from Wkst. E-4,

line 49 see instructions).

52.000

53.00 Nursing and Allied Health Managed Care payment 53.0082,173

54.00 Special add-on payments for new technologies 54.0018,592

55.00 Net organ acquisition cost (Wkst. D-4 Pt. III, col. 1,

line 69)

55.000

56.00 Cost of physicians' services in a teaching hospital (see

intructions)

56.000

57.00 Routine service other pass through costs (from Wkst. D,

Pt. III, column 9, lines 30 through 35).

57.00346,158

58.00 Ancillary service other pass through costs from Wkst. D,

Pt. IV, col. 11 line 200)

58.0083,280

59.00 Total (sum of amounts on lines 49 through 58) 59.0046,628,299

60.00 Primary payer payments 60.0073,910

61.00 Total amount payable for program beneficiaries (line 59

minus line 60)

61.0046,554,389

62.00 Deductibles billed to program beneficiaries 62.003,707,714

63.00 Coinsurance billed to program beneficiaries 63.0062,315

64.00 Allowable bad debts (see instructions) 64.00990,812

65.00 Adjusted reimbursable bad debts (see instructions) 65.00644,028

66.00 Allowable bad debts for dual eligible beneficiaries (see

instructions)

66.00752,232

67.00 Subtotal (line 61 plus line 65 minus lines 62 and 63) 67.0043,428,388

68.00 Credits received from manufacturers for replaced devices

for applicable to MS-DRGs (see instructions)

68.000

69.00 Outlier payments reconciliation (sum of lines 93, 95 and

96).(For SCH see instructions)

69.000

70.00 OTHER ADJUSTMENTS (SEE INSTRUCTIONS) (SPECIFY) 70.000

70.50 RURAL DEMONSTRATION PROJECT 70.500

70.89 Pioneer ACO demonstration payment adjustment amount (see

instructions)

70.890

70.90 HSP bonus payment HVBP adjustment amount (see

instructions)

70.900

70.91 HSP bonus payment HRR adjustment amount (see instructions) 70.910

70.92 Bundled Model 1 discount amount (see instructions) 70.920

70.93 HVBP payment adjustment amount (see instructions) 70.9313,015

70.94 HRR adjustment amount (see instructions) 70.94-184,475

70.95 Recovery of accelerated depreciation 70.950


MCRIF32 - 8.8.159.0 151 | Page


Date/Time Prepared:

Worksheet E

Part A

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



Prior to

October 1

On/After

October 1

0 1.00 2.00

70.96 Low volume adjustment for federal fiscal year (yyyy)

(Enter in column 0 the corresponding federal year for the

period prior to 10/1)

70.960 0

70.97 Low volume adjustment for federal fiscal year (yyyy)

(Enter in column 0 the corresponding federal year for the

period ending on or after 10/1)

70.970 0

70.98 Low Volume Payment-3 70.980

70.99 HAC adjustment amount (see instructions) 70.99459,452

71.00 Amount due provider (line 67 minus lines 68 plus/minus

lines 69 & 70)

71.0042,797,476

71.01 Sequestration adjustment (see instructions) 71.01855,950

72.00 Interim payments 72.0042,069,017

73.00 Tentative settlement (for contractor use only) 73.000

74.00 Balance due provider (Program) (line 71 minus lines 71.01,

72, and 73)

74.00-127,491

75.00 Protested amounts (nonallowable cost report items) in

accordance with CMS Pub. 15-2, chapter 1, §115.2

75.001,037,146

TO BE COMPLETED BY CONTRACTOR (lines 90 through 96)

90.00 Operating outlier amount from Wkst. E, Pt. A, line 2 (see

instructions)

90.002,517,155

91.00 Capital outlier from Wkst. L, Pt. I, line 2 91.00248,232

92.00 Operating outlier reconciliation adjustment amount (see

instructions)

92.000

93.00 Capital outlier reconciliation adjustment amount (see

instructions)

93.000

94.00 The rate used to calculate the time value of money (see

instructions)

94.000.00

95.00 Time value of money for operating expenses (see

instructions)

95.000

96.00 Time value of money for capital related expenses (see

instructions)

96.000

Prior to 10/1 On/After 10/1

1.00 2.00

HSP Bonus Payment Amount

100.00 HSP bonus amount (see instructions) 0 0 100.00

HVBP Adjustment for HSP Bonus Payment

101.00 HVBP adjustment factor (see instructions) 0.0000000000 0.0000000000 101.00

102.00 HVBP adjustment amount for HSP bonus payment (see instructions) 0 0 102.00

HRR Adjustment for HSP Bonus Payment

103.00 HRR adjustment factor (see instructions) 0.0000 0.0000 103.00

104.00 HRR adjustment amount for HSP bonus payment (see instructions) 0 0 104.00


MCRIF32 - 8.8.159.0 152 | Page


Date/Time Prepared:

Worksheet E

Part A Exhibit 5

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110HOSPITAL ACQUIRED CONDITION (HAC) REDUCTION CALCULATION EXHIBIT 5


Wkst. E, Pt.

A, line

Amt. from

Wkst. E, Pt.

A)

Period to

10/01

Period on

after 10/01

Total (cols.

2 and 3)

0 1.00 2.00 3.00 4.00

1.00 DRG amounts other than outlier payments 1.00 1.00

1.01 DRG amounts other than outlier payments for

discharges occurring prior to October 1

1.01 28,618,003 28,618,003 28,618,003 1.01

1.02 DRG amounts other than outlier payments for

discharges occurring on or after October 1

1.02 8,366,433 8,366,433 8,366,433 1.02

1.03 DRG for Federal specific operating payment

for Model 4 BPCI occurring prior to October

1

1.03 0 0 0 1.03

1.04 DRG for Federal specific operating payment

for Model 4 BPCI occurring on or after

October 1

1.04 0 0 0 1.04

2.00 Outlier payments for discharges (see

instructions)

2.00 3,107,252 2,068,645 1,038,607 3,107,252 2.00

2.01 Outlier payments for discharges for Model 4

BPCI

2.02 0 0 0 0 2.01

3.00 Operating outlier reconciliation 2.01 0 0 0 0 3.00

4.00 Managed care simulated payments 3.00 4,971,270 3,802,856 1,168,414 4,971,270 4.00

Indirect Medical Education Adjustment

5.00 Amount from Worksheet E, Part A, line 21

(see instructions)

21.00 0.000000 0.000000 0.000000 5.00

6.00 IME payment adjustment (see instructions) 22.00 0 0 0 0 6.00

6.01 IME payment adjustment for managed care (see

instructions)

22.01 0 0 0 0 6.01

Indirect Medical Education Adjustment for the Add-on for Section 422 of the MMA

7.00 IME payment adjustment factor (see

instructions)

27.00 0.000000 0.000000 0.000000 7.00

8.00 IME adjustment (see instructions) 28.00 0 0 0 0 8.00

8.01 IME payment adjustment add on for managed

care (see instructions)

28.01 0 0 0 0 8.01

9.00 Total IME payment (sum of lines 6 and 8) 29.00 0 0 0 0 9.00

9.01 Total IME payment for managed care (sum of

lines 6.01 and 8.01)

29.01 0 0 0 0 9.01

Disproportionate Share Adjustment

10.00 Allowable disproportionate share percentage

(see instructions)

33.00 0.0935 0.0935 0.0935 10.00

11.00 Disproportionate share adjustment (see

instructions)

34.00 864,511 668,946 195,565 864,511 11.00

11.01 Uncompensated care payments 36.00 1,636,023 1,268,498 367,525 1,636,023 11.01

Additional payment for high percentage of ESRD beneficiary discharges

12.00 Total ESRD additional payment (see

instructions)

46.00 0 0 0 0 12.00

13.00 Subtotal (see instructions) 47.00 42,592,222 32,624,092 9,968,130 42,592,222 13.00

14.00 Hospital specific payments (completed by SCH

and MDH, small rural hospitals only.) (see

instructions)

48.00 0 0 0 0 14.00

15.00 Total payment for inpatient operating costs

(see instructions)

49.00 42,592,222 32,624,092 9,968,130 42,592,222 15.00

16.00 Payment for inpatient program capital 50.00 3,505,874 2,773,422 732,452 3,505,874 16.00

17.00 Special add-on payments for new technologies 54.00 18,592 17,750 842 18,592 17.00

17.01 Net organ aquisition cost 55.00 0 0 0 0 17.01

17.02 Credits received from manufacturers for

replaced devices for applicable MS-DRGs

68.00 0 0 0 0 17.02

18.00 Capital outlier reconciliation adjustment

amount (see instructions)

93.00 0 0 0 0 18.00

19.00 SUBTOTAL 35,415,264 10,701,424 46,116,688 19.00


MCRIF32 - 8.8.159.0 153 | Page


Date/Time Prepared:

Worksheet E

Part A Exhibit 5

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110HOSPITAL ACQUIRED CONDITION (HAC) REDUCTION CALCULATION EXHIBIT 5


Wkst. L, line (Amt. from

Wkst. L)

0 1.00 2.00 3.00 4.00

20.00 Capital DRG other than outlier 1.00 2,932,432 2,270,608 661,824 2,932,432 20.00

20.01 Model 4 BPCI Capital DRG other than outlier 1.01 0 0 0 0 20.01

21.00 Capital DRG outlier payments 2.00 425,061 387,921 37,140 425,061 21.00

21.01 Model 4 BPCI Capital DRG outlier payments 2.01 0 0 0 0 21.01

22.00 Indirect medical education percentage (see

instructions)

5.00 0.0000 0.0000 0.0000 22.00

23.00 Indirect medical education adjustment (see

instructions)

6.00 0 0 0 0 23.00

24.00 Allowable disproportionate share percentage

(see instructions)

10.00 0.0506 0.0506 0.0506 24.00

25.00 Disproportionate share adjustment (see

instructions)

11.00 148,381 114,893 33,488 148,381 25.00

26.00 Total prospective capital payments (see

instructions)

12.00 3,505,874 2,773,422 732,452 3,505,874 26.00

Wkst. E, Pt.

A, line

(Amt. from

Wkst. E, Pt.

A)

0 1.00 2.00 3.00 4.00

27.00 27.00

28.00 Low volume adjustment prior to October 1 70.96 0 0 0 28.00

29.00 Low volume adjustment on or after October 1 70.97 0 0 0 29.00

30.00 HVBP payment adjustment (see instructions) 70.93 13,015 22,831 -9,816 13,015 30.00

30.01 HVBP payment adjustment for HSP bonus

payment (see instructions)

70.90 0 0 0 0 30.01

31.00 HRR adjustment (see instructions) 70.94 -184,475 -111,679 -72,796 -184,475 31.00

31.01 HRR adjustment for HSP bonus payment (see

instructions)

70.91 0 0 0 0 31.01

(Amt. to

Wkst. E, Pt.

A)

0 1.00 2.00 3.00 4.00

32.00 HAC Reduction Program adjustment (see

instructions)

70.99 353,264 106,188 459,452 32.00

100.00 Transfer HAC Reduction Program adjustment to

Wkst. E, Pt. A.

Y 100.00


MCRIF32 - 8.8.159.0 154 | Page


Date/Time Prepared:

Worksheet E

Part B

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



1.00

PART B - MEDICAL AND OTHER HEALTH SERVICES

1.00 Medical and other services (see instructions) 34,017 1.00

2.00 Medical and other services reimbursed under OPPS (see instructions) 31,780,932 2.00

3.00 PPS payments 27,445,200 3.00

4.00 Outlier payment (see instructions) 408,618 4.00

5.00 Enter the hospital specific payment to cost ratio (see instructions) 0.000 5.00

6.00 Line 2 times line 5 0 6.00

7.00 Sum of line 3 plus line 4 divided by line 6 0.00 7.00

8.00 Transitional corridor payment (see instructions) 0 8.00

9.00 Ancillary service other pass through costs from Wkst. D, Pt. IV, col. 13, line 200 72,335 9.00

10.00 Organ acquisitions 0 10.00

11.00 Total cost (sum of lines 1 and 10) (see instructions) 34,017 11.00

COMPUTATION OF LESSER OF COST OR CHARGES

Reasonable charges

12.00 Ancillary service charges 164,118 12.00

13.00 Organ acquisition charges (from Wkst. D-4, Pt. III, col. 4, line 69) 0 13.00

14.00 Total reasonable charges (sum of lines 12 and 13) 164,118 14.00

Customary charges

15.00 Aggregate amount actually collected from patients liable for payment for services on a charge basis 0 15.00

16.00 Amounts that would have been realized from patients liable for payment for services on a chargebasis

had such payment been made in accordance with 42 CFR §413.13(e)

0 16.00

17.00 Ratio of line 15 to line 16 (not to exceed 1.000000) 0.000000 17.00

18.00 Total customary charges (see instructions) 164,118 18.00

19.00 Excess of customary charges over reasonable cost (complete only if line 18 exceeds line 11) (see

instructions)

130,101 19.00

20.00 Excess of reasonable cost over customary charges (complete only if line 11 exceeds line 18) (see

instructions)

0 20.00

21.00 Lesser of cost or charges (line 11 minus line 20) (for CAH see instructions) 34,017 21.00

22.00 Interns and residents (see instructions) 0 22.00

23.00 Cost of physicians' services in a teaching hospital (see instructions) 0 23.00

24.00 Total prospective payment (sum of lines 3, 4, 8 and 9) 27,926,153 24.00

COMPUTATION OF REIMBURSEMENT SETTLEMENT

25.00 Deductibles and coinsurance (for CAH, see instructions) 3,088 25.00

26.00 Deductibles and Coinsurance relating to amount on line 24 (for CAH, see instructions) 5,197,378 26.00

27.00 Subtotal [(lines 21 and 24 minus the sum of lines 25 and 26) plus the sum of lines 22 and 23] (see

instructions)

22,759,704 27.00

28.00 Direct graduate medical education payments (from Wkst. E-4, line 50) 0 28.00

29.00 ESRD direct medical education costs (from Wkst. E-4, line 36) 0 29.00

30.00 Subtotal (sum of lines 27 through 29) 22,759,704 30.00

31.00 Primary payer payments 18,302 31.00

32.00 Subtotal (line 30 minus line 31) 22,741,402 32.00

ALLOWABLE BAD DEBTS (EXCLUDE BAD DEBTS FOR PROFESSIONAL SERVICES)

33.00 Composite rate ESRD (from Wkst. I-5, line 11) 0 33.00

34.00 Allowable bad debts (see instructions) 631,378 34.00

35.00 Adjusted reimbursable bad debts (see instructions) 410,396 35.00

36.00 Allowable bad debts for dual eligible beneficiaries (see instructions) 319,577 36.00

37.00 Subtotal (see instructions) 23,151,798 37.00

38.00 MSP-LCC reconciliation amount from PS&R 562 38.00

39.00 OTHER ADJUSTMENTS (SEE INSTRUCTIONS) (SPECIFY) 0 39.00

39.50 Pioneer ACO demonstration payment adjustment (see instructions) 0 39.50

39.98 Partial or full credits received from manufacturers for replaced devices (see instructions) 0 39.98

39.99 RECOVERY OF ACCELERATED DEPRECIATION 0 39.99


40.01 Sequestration adjustment (see instructions) 463,025 40.01

41.00 Interim payments 22,824,841 41.00

42.00 Tentative settlement (for contractors use only) 0 42.00

43.00 Balance due provider/program (see instructions) -136,630 43.00

44.00 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, chapter 1,

§115.2

0 44.00

TO BE COMPLETED BY CONTRACTOR

90.00 Original outlier amount (see instructions) 0 90.00

91.00 Outlier reconciliation adjustment amount (see instructions) 0 91.00

92.00 The rate used to calculate the Time Value of Money 0.00 92.00

93.00 Time Value of Money (see instructions) 0 93.00

94.00 Total (sum of lines 91 and 93) 0 94.00


MCRIF32 - 8.8.159.0 155 | Page


Date/Time Prepared:

Worksheet E

Part B

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110


CALCULATION OF REIMBURSEMENT SETTLEMENT


IPF

PPS

1.00


1.00 Medical and other services (see instructions) 43 1.00

2.00 Medical and other services reimbursed under OPPS (see instructions) 509 2.00

3.00 PPS payments 380 3.00

4.00 Outlier payment (see instructions) 0 4.00





9.00 Ancillary service other pass through costs from Wkst. D, Pt. IV, col. 13, line 200 2 9.00


11.00 Total cost (sum of lines 1 and 10) (see instructions) 43 11.00


Reasonable charges

12.00 Ancillary service charges 198 12.00


14.00 Total reasonable charges (sum of lines 12 and 13) 198 14.00

Customary charges




0 16.00


18.00 Total customary charges (see instructions) 198 18.00


instructions)

155 19.00


instructions)

0 20.00

21.00 Lesser of cost or charges (line 11 minus line 20) (for CAH see instructions) 43 21.00



24.00 Total prospective payment (sum of lines 3, 4, 8 and 9) 382 24.00


25.00 Deductibles and coinsurance (for CAH, see instructions) 0 25.00

26.00 Deductibles and Coinsurance relating to amount on line 24 (for CAH, see instructions) 102 26.00


instructions)

323 27.00



30.00 Subtotal (sum of lines 27 through 29) 323 30.00

31.00 Primary payer payments 0 31.00

32.00 Subtotal (line 30 minus line 31) 323 32.00



34.00 Allowable bad debts (see instructions) 0 34.00

35.00 Adjusted reimbursable bad debts (see instructions) 0 35.00

36.00 Allowable bad debts for dual eligible beneficiaries (see instructions) 0 36.00

37.00 Subtotal (see instructions) 323 37.00







40.01 Sequestration adjustment (see instructions) 6 40.01

41.00 Interim payments 311 41.00


43.00 Balance due provider/program (see instructions) 6 43.00


§115.2

0 44.00








MCRIF32 - 8.8.159.0 156 | Page


Date/Time Prepared:

Worksheet E

Part B

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110




IRF

PPS

1.00


1.00 Medical and other services (see instructions) 0 1.00

2.00 Medical and other services reimbursed under OPPS (see instructions) 365 2.00

3.00 PPS payments 56 3.00

4.00 Outlier payment (see instructions) 0 4.00





9.00 Ancillary service other pass through costs from Wkst. D, Pt. IV, col. 13, line 200 2 9.00


11.00 Total cost (sum of lines 1 and 10) (see instructions) 0 11.00


Reasonable charges

12.00 Ancillary service charges 0 12.00


14.00 Total reasonable charges (sum of lines 12 and 13) 0 14.00

Customary charges




0 16.00


18.00 Total customary charges (see instructions) 0 18.00


instructions)

0 19.00


instructions)

0 20.00

21.00 Lesser of cost or charges (line 11 minus line 20) (for CAH see instructions) 0 21.00



24.00 Total prospective payment (sum of lines 3, 4, 8 and 9) 58 24.00


25.00 Deductibles and coinsurance (for CAH, see instructions) 0 25.00

26.00 Deductibles and Coinsurance relating to amount on line 24 (for CAH, see instructions) 11 26.00


instructions)

47 27.00



30.00 Subtotal (sum of lines 27 through 29) 47 30.00


32.00 Subtotal (line 30 minus line 31) 47 32.00
















43.00 Balance due provider/program (see instructions) 2 43.00


§115.2

0 44.00








MCRIF32 - 8.8.159.0 157 | Page


Date/Time Prepared:

Worksheet E-1

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110ANALYSIS OF PAYMENTS TO PROVIDERS FOR SERVICES RENDERED


Inpatient Part A Part B

mm/dd/yyyy Amount mm/dd/yyyy Amount

1.00 2.00 3.00 4.00

1.00 Total interim payments paid to provider 1.0041,908,017 22,681,741

2.00 Interim payments payable on individual bills, either

submitted or to be submitted to the contractor for

services rendered in the cost reporting period. If none,

write "NONE" or enter a zero

2.000 0

3.00 List separately each retroactive lump sum adjustment

amount based on subsequent revision of the interim rate

for the cost reporting period. Also show date of each

payment. If none, write "NONE" or enter a zero. (1)

3.00

Program to Provider

3.01 ADJUSTMENTS TO PROVIDER 3.0109/30/2015 1,916,000 08/10/2015 143,100

3.02 3.020 0

3.03 3.030 0

3.04 3.040 0

3.05 3.050 0

Provider to Program

3.50 ADJUSTMENTS TO PROGRAM 3.5004/07/2016 1,755,000 0

3.51 3.510 0

3.52 3.520 0

3.53 3.530 0

3.54 3.540 0

3.99 Subtotal (sum of lines 3.01-3.49 minus sum of lines

3.50-3.98)

3.99161,000 143,100

4.00 Total interim payments (sum of lines 1, 2, and 3.99)

(transfer to Wkst. E or Wkst. E-3, line and column as

appropriate)

4.0042,069,017 22,824,841


5.00 List separately each tentative settlement payment after

desk review. Also show date of each payment. If none,

write "NONE" or enter a zero. (1)

5.00

Program to Provider

5.01 TENTATIVE TO PROVIDER 5.010 0

5.02 5.020 0

5.03 5.030 0

Provider to Program

5.50 TENTATIVE TO PROGRAM 5.500 0

5.51 5.510 0

5.52 5.520 0


5.50-5.98)

5.990 0

6.00 Determined net settlement amount (balance due) based on

the cost report. (1)

6.00

6.01 SETTLEMENT TO PROVIDER 6.010 0

6.02 SETTLEMENT TO PROGRAM 6.02127,491 136,630

7.00 Total Medicare program liability (see instructions) 7.0041,941,526 22,688,211

Contractor

Number

NPR Date

(Mo/Day/Yr)

0 1.00 2.00

8.00 Name of Contractor 8.00CMS HCRIS PUF 99999


MCRIF32 - 8.8.159.0 158 | Page


Date/Time Prepared:

Worksheet E-1

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110


ANALYSIS OF PAYMENTS TO PROVIDERS FOR SERVICES RENDERED


IPF

PPS



1.00 2.00 3.00 4.00

1.00 Total interim payments paid to provider 1.00518,017 311





2.000 0





3.00

Program to Provider

3.01 ADJUSTMENTS TO PROVIDER 3.010 0

3.02 3.020 0

3.03 3.030 0

3.04 3.040 0

3.05 3.050 0

Provider to Program

3.50 ADJUSTMENTS TO PROGRAM 3.500 0

3.51 3.510 0

3.52 3.520 0

3.53 3.530 0

3.54 3.540 0


3.50-3.98)

3.990 0



appropriate)

4.00518,017 311





5.00

Program to Provider


5.02 5.020 0

5.03 5.030 0

Provider to Program


5.51 5.510 0

5.52 5.520 0


5.50-5.98)

5.990 0



6.00

6.01 SETTLEMENT TO PROVIDER 6.0118,383 6

6.02 SETTLEMENT TO PROGRAM 6.020 0

7.00 Total Medicare program liability (see instructions) 7.00536,400 317

Contractor

Number

NPR Date

(Mo/Day/Yr)

0 1.00 2.00



MCRIF32 - 8.8.159.0 159 | Page


Date/Time Prepared:

Worksheet E-1

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110


ANALYSIS OF PAYMENTS TO PROVIDERS FOR SERVICES RENDERED


IRF

PPS



1.00 2.00 3.00 4.00

1.00 Total interim payments paid to provider 1.002,364,515 44





2.000 0





3.00

Program to Provider

3.01 ADJUSTMENTS TO PROVIDER 3.010 0

3.02 3.020 0

3.03 3.030 0

3.04 3.040 0

3.05 3.050 0

Provider to Program

3.50 ADJUSTMENTS TO PROGRAM 3.500 0

3.51 3.510 0

3.52 3.520 0

3.53 3.530 0

3.54 3.540 0


3.50-3.98)

3.990 0



appropriate)

4.002,364,515 44





5.00

Program to Provider


5.02 5.020 0

5.03 5.030 0

Provider to Program


5.51 5.510 0

5.52 5.520 0


5.50-5.98)

5.990 0



6.00

6.01 SETTLEMENT TO PROVIDER 6.0140,567 2


7.00 Total Medicare program liability (see instructions) 7.002,405,082 46

Contractor

Number

NPR Date

(Mo/Day/Yr)

0 1.00 2.00



MCRIF32 - 8.8.159.0 160 | Page


Date/Time Prepared:

Worksheet E-1

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110CALCULATION OF REIMBURSEMENT SETTLEMENT FOR HIT


1.00

TO BE COMPLETED BY CONTRACTOR FOR NONSTANDARD COST REPORTS

HEALTH INFORMATION TECHNOLOGY DATA COLLECTION AND CALCULATION

1.00 Total hospital discharges as defined in AARA §4102 from Wkst. S-3, Pt. I col. 15 line 14 8,160 1.00

2.00 Medicare days from Wkst. S-3, Pt. I, col. 6 sum of lines 1, 8-12 18,790 2.00

3.00 Medicare HMO days from Wkst. S-3, Pt. I, col. 6. line 2 2,512 3.00

4.00 Total inpatient days from S-3, Pt. I col. 8 sum of lines 1, 8-12 32,573 4.00

5.00 Total hospital charges from Wkst C, Pt. I, col. 8 line 200 833,226,171 5.00

6.00 Total hospital charity care charges from Wkst. S-10, col. 3 line 20 11,938,845 6.00

7.00 CAH only - The reasonable cost incurred for the purchase of certified HIT technology Wkst. S-2, Pt. I

line 168

0 7.00

8.00 Calculation of the HIT incentive payment (see instructions) 1,128,680 8.00

9.00 Sequestration adjustment amount (see instructions) 22,574 9.00

10.00 Calculation of the HIT incentive payment after sequestration (see instructions) 1,106,106 10.00

INPATIENT HOSPITAL SERVICES UNDER THE IPPS & CAH

30.00 Initial/interim HIT payment adjustment (see instructions) 1,090,075 30.00

31.00 Other Adjustment (specify) 0 31.00

32.00 Balance due provider (line 8 (or line 10) minus line 30 and line 31) (see instructions) 16,031 32.00


MCRIF32 - 8.8.159.0 161 | Page


Date/Time Prepared:

Worksheet E-3

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110




IPF

PPS

1.00

PART II - MEDICARE PART A SERVICES - IPF PPS

1.00 Net Federal IPF PPS Payments (excluding outlier, ECT, and medical education payments) 657,439 1.00

2.00 Net IPF PPS Outlier Payments 6,786 2.00

3.00 Net IPF PPS ECT Payments 0 3.00

4.00 Unweighted intern and resident FTE count in the most recent cost report filed on or before November

15, 2004. (see instructions)

0.00 4.00

4.01 Cap increases for the unweighted intern and resident FTE count for residents that were displaced by

program or hospital closure, that would not be counted without a temporary cap adjustment under 42

CFR §412.424(d)(1)(iii)(F)(1) or (2) (see instructions)

0.00 4.01

5.00 New Teaching program adjustment. (see instructions) 0.00 5.00

6.00 Current year's unweighted FTE count of I&R excluding FTEs in the new program growth period of a "new

teaching program" (see instuctions)

0.00 6.00

7.00 Current year's unweighted I&R FTE count for residents within the new program growth period of a "new

teaching program" (see instuctions)

0.00 7.00

8.00 Intern and resident count for IPF PPS medical education adjustment (see instructions) 0.00 8.00

9.00 Average Daily Census (see instructions) 8.021918 9.00

10.00 Teaching Adjustment Factor {((1 + (line 8/line 9)) raised to the power of .5150 -1}. 0.000000 10.00

11.00 Teaching Adjustment (line 1 multiplied by line 10). 0 11.00

12.00 Adjusted Net IPF PPS Payments (sum of lines 1, 2, 3 and 11) 664,225 12.00

13.00 Nursing and Allied Health Managed Care payment (see instruction) 0 13.00

14.00 Organ acquisition (DO NOT USE THIS LINE) 14.00


16.00 Subtotal (see instructions) 664,225 16.00


18.00 Subtotal (line 16 less line 17). 664,225 18.00

19.00 Deductibles 148,724 19.00

20.00 Subtotal (line 18 minus line 19) 515,501 20.00

21.00 Coinsurance 16,380 21.00

22.00 Subtotal (line 20 minus line 21) 499,121 22.00

23.00 Allowable bad debts (exclude bad debts for professional services) (see instructions) 41,058 23.00

24.00 Adjusted reimbursable bad debts (see instructions) 26,688 24.00

25.00 Allowable bad debts for dual eligible beneficiaries (see instructions) 26,203 25.00

26.00 Subtotal (sum of lines 22 and 24) 525,809 26.00


28.00 Other pass through costs (see instructions) 21,538 28.00

29.00 Outlier payments reconciliation 0 29.00



30.99 Recovery of Accelerated Depreciation 0 30.99

31.00 Total amount payable to the provider (see instructions) 547,347 31.00


32.00 Interim payments 518,017 32.00

33.00 Tentative settlement (for contractor use only) 0 33.00

34.00 Balance due provider/program (line 31 minus lines 31.01, 32 and 33) 18,383 34.00


§115.2

0 35.00


50.00 Original outlier amount from Worksheet E-3, Part II, line 2 6,786 50.00





MCRIF32 - 8.8.159.0 162 | Page


Date/Time Prepared:

Worksheet E-3

Part III

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110




IRF

PPS

1.00

PART III - MEDICARE PART A SERVICES - IRF PPS

1.00 Net Federal PPS Payment (see instructions) 2,302,235 1.00

2.00 Medicare SSI ratio (IRF PPS only) (see instructions) 0.0324 2.00

3.00 Inpatient Rehabilitation LIP Payments (see instructions) 92,550 3.00

4.00 Outlier Payments 34,416 4.00

5.00 Unweighted intern and resident FTE count in the most recent cost reporting period ending on or prior

to November 15, 2004 (see instructions)

0.00 5.00

5.01 Cap increases for the unweighted intern and resident FTE count for residents that were displaced by

program or hospital closure, that would not be counted without a temporary cap adjustment under 42

CFR §412.424(d)(1)(iii)(F)(1) or (2) (see instructions)

0.00 5.01

6.00 New Teaching program adjustment. (see instructions) 0.00 6.00

7.00 Current year's unweighted FTE count of I&R excluding FTEs in the new program growth period of a "new

teaching program" (see instructions)

0.00 7.00

8.00 Current year's unweighted I&R FTE count for residents within the new program growth period of a "new

teaching program" (see instructions)

0.00 8.00

9.00 Intern and resident count for IRF PPS medical education adjustment (see instructions) 0.00 9.00

10.00 Average Daily Census (see instructions) 6.432877 10.00

11.00 Teaching Adjustment Factor (see instructions) 0.000000 11.00

12.00 Teaching Adjustment (see instructions) 0 12.00

13.00 Total PPS Payment (see instructions) 2,429,201 13.00

14.00 Nursing and Allied Health Managed Care payments (see instruction) 0 14.00

15.00 Organ acquisition (DO NOT USE THIS LINE) 15.00




19.00 Subtotal (line 17 less line 18). 2,429,201 19.00

20.00 Deductibles 7,560 20.00


22.00 Coinsurance 1,890 22.00


24.00 Allowable bad debts (exclude bad debts for professional services) (see instructions) 0 24.00



27.00 Subtotal (sum of lines 23 and 25) 2,419,751 27.00


29.00 Other pass through costs (see instructions) 34,414 29.00

30.00 Outlier payments reconciliation 0 30.00



31.99 Recovery of Accelerated Depreciation 0 31.99

32.00 Total amount payable to the provider (see instructions) 2,454,165 32.00


33.00 Interim payments 2,364,515 33.00


35.00 Balance due provider/program (line 32 minus lines 32.01, 33, and 34) 40,567 35.00


§115.2

0 36.00


50.00 Original outlier amount from Wkst. E-3, Pt. III, line 4 34,416 50.00





MCRIF32 - 8.8.159.0 163 | Page


Date/Time Prepared:

Worksheet E-3

Part VII

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015



Inpatient Outpatient

1.00 2.00

PART VII - CALCULATION OF REIMBURSEMENT - ALL OTHER HEALTH SERVICES FOR TITLES V OR XIX SERVICES

COMPUTATION OF NET COST OF COVERED SERVICES

1.00 Inpatient hospital/SNF/NF services 7,318,292 1.00

2.00 Medical and other services 11,822,752 2.00

3.00 Organ acquisition (certified transplant centers only) 0 3.00

4.00 Subtotal (sum of lines 1, 2 and 3) 7,318,292 11,822,752 4.00

5.00 Inpatient primary payer payments 903,886 5.00

6.00 Outpatient primary payer payments 278,991 6.00

7.00 Subtotal (line 4 less sum of lines 5 and 6) 6,414,406 11,543,761 7.00


Reasonable Charges

8.00 Routine service charges 3,968,828 8.00

9.00 Ancillary service charges 16,034,774 60,539,827 9.00

10.00 Organ acquisition charges, net of revenue 0 10.00

11.00 Incentive from target amount computation 0 11.00

12.00 Total reasonable charges (sum of lines 8 through 11) 20,003,602 60,539,827 12.00

CUSTOMARY CHARGES

13.00 Amount actually collected from patients liable for payment for services on a charge

basis

0 0 13.00

14.00 Amounts that would have been realized from patients liable for payment for services on

a charge basis had such payment been made in accordance with 42 CFR §413.13(e)

0 0 14.00

15.00 Ratio of line 13 to line 14 (not to exceed 1.000000) 0.000000 0.000000 15.00

16.00 Total customary charges (see instructions) 20,003,602 60,539,827 16.00

17.00 Excess of customary charges over reasonable cost (complete only if line 16 exceeds

line 4) (see instructions)

12,685,310 48,717,075 17.00

18.00 Excess of reasonable cost over customary charges (complete only if line 4 exceeds line

16) (see instructions)

0 0 18.00

19.00 Interns and Residents (see instructions) 0 0 19.00

20.00 Cost of physicians' services in a teaching hospital (see instructions) 0 0 20.00

21.00 Cost of covered services (enter the lesser of line 4 or line 16) 7,318,292 11,822,752 21.00

PROSPECTIVE PAYMENT AMOUNT - Lines 22 through 26 must only be completed for PPS providers.

22.00 Other than outlier payments 0 0 22.00

23.00 Outlier payments 0 0 23.00

24.00 Program capital payments 0 24.00

25.00 Capital exception payments (see instructions) 0 25.00

26.00 Routine and Ancillary service other pass through costs 0 0 26.00

27.00 Subtotal (sum of lines 22 through 26) 0 0 27.00

28.00 Customary charges (title V or XIX PPS covered services only) 0 0 28.00

29.00 Titles V or XIX (sum of lines 21 and 27) 7,318,292 11,822,752 29.00


30.00 Excess of reasonable cost (from line 18) 0 0 30.00

31.00 Subtotal (sum of lines 19 and 20, plus 29 minus lines 5 and 6) 6,414,406 11,543,761 31.00

32.00 Deductibles 0 0 32.00

33.00 Coinsurance 1,360 19,242 33.00

34.00 Allowable bad debts (see instructions) 0 0 34.00

35.00 Utilization review 0 35.00

36.00 Subtotal (sum of lines 31, 34 and 35 minus sum of lines 32 and 33) 6,413,046 11,524,519 36.00

37.00 OTHER ADJUSTMENTS (SEE INSTRUCTIONS) (SPECIFY) 0 0 37.00

38.00 Subtotal (line 36 ± line 37) 6,413,046 11,524,519 38.00

39.00 Direct graduate medical education payments (from Wkst. E-4) 0 39.00

40.00 Total amount payable to the provider (sum of lines 38 and 39) 6,413,046 11,524,519 40.00

41.00 Interim payments 5,004,037 12,081,248 41.00

42.00 Balance due provider/program (line 40 minus line 41) 1,409,009 -556,729 42.00

43.00 Protested amounts (nonallowable cost report items) in accordance with CMS Pub 15-2,

chapter 1, §115.2

0 0 43.00


MCRIF32 - 8.8.159.0 164 | Page


Date/Time Prepared:

Worksheet E-3

Part VII

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110




IPF

Cost


1.00 2.00



1.00 Inpatient hospital/SNF/NF services 672,281 1.00

2.00 Medical and other services 0 2.00


4.00 Subtotal (sum of lines 1, 2 and 3) 672,281 0 4.00


6.00 Outpatient primary payer payments 0 6.00

7.00 Subtotal (line 4 less sum of lines 5 and 6) 630,018 0 7.00


Reasonable Charges

8.00 Routine service charges 727,006 8.00

9.00 Ancillary service charges 208,301 0 9.00



12.00 Total reasonable charges (sum of lines 8 through 11) 935,307 0 12.00

CUSTOMARY CHARGES


basis

0 0 13.00



0 0 14.00


16.00 Total customary charges (see instructions) 935,307 0 16.00



263,026 0 17.00



0 0 18.00



21.00 Cost of covered services (enter the lesser of line 4 or line 16) 672,281 0 21.00









29.00 Titles V or XIX (sum of lines 21 and 27) 672,281 0 29.00



31.00 Subtotal (sum of lines 19 and 20, plus 29 minus lines 5 and 6) 630,018 0 31.00


33.00 Coinsurance 0 0 33.00



36.00 Subtotal (sum of lines 31, 34 and 35 minus sum of lines 32 and 33) 630,018 0 36.00


38.00 Subtotal (line 36 ± line 37) 630,018 0 38.00


40.00 Total amount payable to the provider (sum of lines 38 and 39) 630,018 0 40.00

41.00 Interim payments 233,973 0 41.00

42.00 Balance due provider/program (line 40 minus line 41) 396,045 0 42.00


chapter 1, §115.2

0 0 43.00


MCRIF32 - 8.8.159.0 165 | Page


Date/Time Prepared:

Worksheet E-3

Part VII

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110




IRF

Cost


1.00 2.00



1.00 Inpatient hospital/SNF/NF services 224,789 1.00

2.00 Medical and other services 0 2.00


4.00 Subtotal (sum of lines 1, 2 and 3) 224,789 0 4.00


6.00 Outpatient primary payer payments 0 6.00

7.00 Subtotal (line 4 less sum of lines 5 and 6) 202,369 0 7.00


Reasonable Charges

8.00 Routine service charges 92,743 8.00

9.00 Ancillary service charges 403,432 0 9.00



12.00 Total reasonable charges (sum of lines 8 through 11) 496,175 0 12.00

CUSTOMARY CHARGES


basis

0 0 13.00



0 0 14.00


16.00 Total customary charges (see instructions) 496,175 0 16.00



271,386 0 17.00



0 0 18.00



21.00 Cost of covered services (enter the lesser of line 4 or line 16) 224,789 0 21.00









29.00 Titles V or XIX (sum of lines 21 and 27) 224,789 0 29.00



31.00 Subtotal (sum of lines 19 and 20, plus 29 minus lines 5 and 6) 202,369 0 31.00


33.00 Coinsurance 0 0 33.00



36.00 Subtotal (sum of lines 31, 34 and 35 minus sum of lines 32 and 33) 202,369 0 36.00


38.00 Subtotal (line 36 ± line 37) 202,369 0 38.00


40.00 Total amount payable to the provider (sum of lines 38 and 39) 202,369 0 40.00

41.00 Interim payments 124,121 0 41.00

42.00 Balance due provider/program (line 40 minus line 41) 78,248 0 42.00


chapter 1, §115.2

0 0 43.00


MCRIF32 - 8.8.159.0 166 | Page


Date/Time Prepared:

Worksheet G

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110BALANCE SHEET (If you are nonproprietary and do not maintain

fund-type accounting records, complete the General Fund column only)

General Fund Specific

Purpose Fund

Endowment

Fund

Plant Fund

1.00 2.00 3.00 4.00

CURRENT ASSETS

1.00 Cash on hand in banks 1.0021,294,494 0 0 0

2.00 Temporary investments 2.001,106,404 0 0 0

3.00 Notes receivable 3.0040,118,955 0 0 0

4.00 Accounts receivable 4.00152,552,088 0 0 0

5.00 Other receivable 5.002,632,171 0 0 0

6.00 Allowances for uncollectible notes and accounts receivable 6.00-119,634,848 0 0 0

7.00 Inventory 7.007,145,680 0 0 0

8.00 Prepaid expenses 8.003,191,679 0 0 0

9.00 Other current assets 9.000 0 0 0

10.00 Due from other funds 10.001,090,075 0 0 0

11.00 Total current assets (sum of lines 1-10) 11.00109,496,698 0 0 0

FIXED ASSETS

12.00 Land 12.0017,698,441 0 0 0

13.00 Land improvements 13.0013,097,991 0 0 0

14.00 Accumulated depreciation 14.00-8,128,901 0 0 0

15.00 Buildings 15.00200,304,533 0 0 0


17.00 Leasehold improvements 17.000 0 0 0

18.00 Accumulated depreciation 18.000 0 0 0

19.00 Fixed equipment 19.000 0 0 0


21.00 Automobiles and trucks 21.000 0 0 0


23.00 Major movable equipment 23.00137,124,132 0 0 0


25.00 Minor equipment depreciable 25.000 0 0 0


27.00 HIT designated Assets 27.000 0 0 0


29.00 Minor equipment-nondepreciable 29.000 0 0 0

30.00 Total fixed assets (sum of lines 12-29) 30.00158,928,209 0 0 0

OTHER ASSETS

31.00 Investments 31.008,190,803 0 0 0

32.00 Deposits on leases 32.000 0 0 0

33.00 Due from owners/officers 33.000 0 0 0

34.00 Other assets 34.009,751,860 0 0 0

35.00 Total other assets (sum of lines 31-34) 35.0017,942,663 0 0 0

36.00 Total assets (sum of lines 11, 30, and 35) 36.00286,367,570 0 0 0

CURRENT LIABILITIES

37.00 Accounts payable 37.0020,662,236 0 0 0

38.00 Salaries, wages, and fees payable 38.009,420,323 0 0 0

39.00 Payroll taxes payable 39.000 0 0 0

40.00 Notes and loans payable (short term) 40.003,085,106 0 0 0

41.00 Deferred income 41.000 0 0 0

42.00 Accelerated payments 42.000

43.00 Due to other funds 43.0011,503,942 0 0 0

44.00 Other current liabilities 44.003,405,104 0 0 0

45.00 Total current liabilities (sum of lines 37 thru 44) 45.0048,076,711 0 0 0

LONG TERM LIABILITIES

46.00 Mortgage payable 46.000 0 0 0

47.00 Notes payable 47.00110,460,320 0 0 0

48.00 Unsecured loans 48.000 0 0 0

49.00 Other long term liabilities 49.006,661,742 0 0 0

50.00 Total long term liabilities (sum of lines 46 thru 49 50.00117,122,062 0 0 0

51.00 Total liabilites (sum of lines 45 and 50) 51.00165,198,773 0 0 0

CAPITAL ACCOUNTS

52.00 General fund balance 52.00121,168,797

53.00 Specific purpose fund 53.000

54.00 Donor created - endowment fund balance - restricted 54.000

55.00 Donor created - endowment fund balance - unrestricted 55.000

56.00 Governing body created - endowment fund balance 56.000

57.00 Plant fund balance - invested in plant 57.000

58.00 Plant fund balance - reserve for plant improvement,

replacement, and expansion

58.000

59.00 Total fund balances (sum of lines 52 thru 58) 59.00121,168,797 0 0 0

60.00 Total liabilities and fund balances (sum of lines 51 and

59)

60.00286,367,570 0 0 0


MCRIF32 - 8.8.159.0 167 | Page


Date/Time Prepared:

Worksheet G-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110STATEMENT OF CHANGES IN FUND BALANCES

General Fund Special Purpose Fund Endowment

Fund

1.00 2.00 3.00 4.00 5.00

1.00 Fund balances at beginning of period 120,869,364 0 1.00

2.00 Net income (loss) (from Wkst. G-3, line 29) 5,578,641 2.00

3.00 Total (sum of line 1 and line 2) 126,448,005 0 3.00

4.00 INCREASE IN PRNA 12,538 0 0 4.00

5.00 0 0 0 5.00

6.00 0 0 0 6.00

7.00 0 0 0 7.00

8.00 0 0 0 8.00

9.00 0 0 0 9.00

10.00 Total additions (sum of line 4-9) 12,538 0 10.00

11.00 Subtotal (line 3 plus line 10) 126,460,543 0 11.00

12.00 DECREASE IN TRNA 57,647 0 0 12.00

13.00 TRANSFER TO AFFILIATES 5,234,099 0 0 13.00

14.00 0 0 0 14.00

15.00 0 0 0 15.00

16.00 0 0 0 16.00

17.00 0 0 0 17.00

18.00 Total deductions (sum of lines 12-17) 5,291,746 0 18.00

19.00 Fund balance at end of period per balance

sheet (line 11 minus line 18)

121,168,797 0 19.00

Endowment

Fund

Plant Fund

6.00 7.00 8.00

1.00 Fund balances at beginning of period 0 0 1.00

2.00 Net income (loss) (from Wkst. G-3, line 29) 2.00

3.00 Total (sum of line 1 and line 2) 0 0 3.00

4.00 INCREASE IN PRNA 0 4.00

5.00 0 5.00

6.00 0 6.00

7.00 0 7.00

8.00 0 8.00

9.00 0 9.00

10.00 Total additions (sum of line 4-9) 0 0 10.00

11.00 Subtotal (line 3 plus line 10) 0 0 11.00

12.00 DECREASE IN TRNA 0 12.00

13.00 TRANSFER TO AFFILIATES 0 13.00

14.00 0 14.00

15.00 0 15.00

16.00 0 16.00

17.00 0 17.00

18.00 Total deductions (sum of lines 12-17) 0 0 18.00

19.00 Fund balance at end of period per balance

sheet (line 11 minus line 18)

0 0 19.00


MCRIF32 - 8.8.159.0 168 | Page


Date/Time Prepared:

Worksheet G-2

Parts I & II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110STATEMENT OF PATIENT REVENUES AND OPERATING EXPENSES

Cost Center Description Inpatient Outpatient Total

1.00 2.00 3.00

PART I - PATIENT REVENUES

General Inpatient Routine Services

1.00 Hospital 23,087,935 23,087,935 1.00

2.00 SUBPROVIDER - IPF 2,645,527 2,645,527 2.00

3.00 SUBPROVIDER - IRF 1,384,565 1,384,565 3.00


5.00 Swing bed - SNF 0 0 5.00

6.00 Swing bed - NF 0 0 6.00




10.00 Total general inpatient care services (sum of lines 1-9) 27,118,027 27,118,027 10.00

Intensive Care Type Inpatient Hospital Services




13.01 ADULT SPECIAL CARE 6,480,124 6,480,124 13.01


14.01 CARDIOTHORACIC ICU 3,565,208 3,565,208 14.01


16.00 Total intensive care type inpatient hospital services (sum of lines

11-15)

10,045,332 10,045,332 16.00

17.00 Total inpatient routine care services (sum of lines 10 and 16) 37,163,359 37,163,359 17.00

18.00 Ancillary services 342,089,521 0 342,089,521 18.00

19.00 Outpatient services 0 442,692,875 442,692,875 19.00

20.00 RURAL HEALTH CLINIC 0 0 0 20.00

20.01 RURAL HEALTH CLINIC II 0 3,642,310 3,642,310 20.01

20.02 RURAL HEALTH CLINIC III 0 3,451,296 3,451,296 20.02

21.00 FEDERALLY QUALIFIED HEALTH CENTER 0 0 0 21.00

22.00 HOME HEALTH AGENCY 1,426,971 1,426,971 22.00

23.00 AMBULANCE SERVICES 23.00

24.00 CMHC 24.00


26.00 HOSPICE 0 2,759,839 2,759,839 26.00

27.00 PHYSICIAN OFFICES 80 38,643,266 38,643,346 27.00

27.01 OUTREACH LAB 0 0 0 27.01

27.02 EMPLOYEE CHARGES 5,484,444 15,203,142 20,687,586 27.02

27.03 PROFESSIONAL CHARGES 5,660,097 36,661,381 42,321,478 27.03

28.00 Total patient revenues (sum of lines 17-27)(transfer column 3 to Wkst.

G-3, line 1)

390,397,501 544,481,080 934,878,581 28.00

PART II - OPERATING EXPENSES

29.00 Operating expenses (per Wkst. A, column 3, line 200) 308,287,712 29.00

30.00 0 30.00

31.00 0 31.00

32.00 0 32.00

33.00 0 33.00

34.00 0 34.00

35.00 0 35.00

36.00 Total additions (sum of lines 30-35) 0 36.00

37.00 0 37.00

38.00 0 38.00

39.00 0 39.00

40.00 0 40.00

41.00 0 41.00

42.00 Total deductions (sum of lines 37-41) 0 42.00

43.00 Total operating expenses (sum of lines 29 and 36 minus line 42)(transfer

to Wkst. G-3, line 4)

308,287,712 43.00


MCRIF32 - 8.8.159.0 169 | Page


Date/Time Prepared:

Worksheet G-3

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110STATEMENT OF REVENUES AND EXPENSES

1.00

1.00 Total patient revenues (from Wkst. G-2, Part I, column 3, line 28) 934,878,581 1.00

2.00 Less contractual allowances and discounts on patients' accounts 644,914,094 2.00

3.00 Net patient revenues (line 1 minus line 2) 289,964,487 3.00

4.00 Less total operating expenses (from Wkst. G-2, Part II, line 43) 308,287,712 4.00

5.00 Net income from service to patients (line 3 minus line 4) -18,323,225 5.00

OTHER INCOME

6.00 Contributions, donations, bequests, etc 80,047 6.00

7.00 Income from investments 409,027 7.00

8.00 Revenues from telephone and other miscellaneous communication services 0 8.00

9.00 Revenue from television and radio service 0 9.00

10.00 Purchase discounts 0 10.00

11.00 Rebates and refunds of expenses 0 11.00

12.00 Parking lot receipts 0 12.00

13.00 Revenue from laundry and linen service 0 13.00

14.00 Revenue from meals sold to employees and guests 679,561 14.00

15.00 Revenue from rental of living quarters 0 15.00

16.00 Revenue from sale of medical and surgical supplies to other than patients 0 16.00

17.00 Revenue from sale of drugs to other than patients 5,729,560 17.00

18.00 Revenue from sale of medical records and abstracts 0 18.00

19.00 Tuition (fees, sale of textbooks, uniforms, etc.) 2,837,837 19.00

20.00 Revenue from gifts, flowers, coffee shops, and canteen 0 20.00

21.00 Rental of vending machines 0 21.00

22.00 Rental of hospital space 0 22.00

23.00 Governmental appropriations 0 23.00

24.00 BUILDING BLOCKS GRANT 958,959 24.00

24.01 HEALTHPOINT 3,525,811 24.01

24.02 PRISONER MEALS 45,327 24.02

24.03 OUTREACH LAB 432,156 24.03

24.04 RENTAL INCOME 738,654 24.04

24.05 MISC OTHER OPERATING REVENUE 2,847,694 24.05

24.06 RENTAL INCOME - INTERNAL 4,969,539 24.06

24.07 GAIN ON DISPOSALS 0 24.07

24.08 340B PHARMACY 854,873 24.08

24.09 LOSS ON EQUIPMENT DISPOSAL -207,180 24.09

24.10 ROUNDING 1 24.10

24.11 0 24.11

24.12 0 24.12

24.13 0 24.13

24.14 0 24.14

24.15 0 24.15

24.16 0 24.16

24.17 0 24.17

24.18 0 24.18

25.00 Total other income (sum of lines 6-24) 23,901,866 25.00

26.00 Total (line 5 plus line 25) 5,578,641 26.00

27.00 0 27.00

27.01 0 27.01

27.02 0 27.02

27.03 0 27.03

27.04 0 27.04

27.05 0 27.05

27.06 0 27.06

28.00 Total other expenses (sum of line 27 and subscripts) 0 28.00

29.00 Net income (or loss) for the period (line 26 minus line 28) 5,578,641 29.00


MCRIF32 - 8.8.159.0 170 | Page


Date/Time Prepared:

Worksheet H

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

HHA CCN: 267121

ANALYSIS OF PROVIDER-BASED HOME HEALTH AGENCY COSTS

Home Health

Agency I

PPS

Salaries Employee

Benefits

Transportatio

n (see

instructions)

Contracted/Pu

rchased

Services

Other Costs Total (sum of

cols. 1 thru

5)

1.00 2.00 3.00 4.00 5.00 6.00


1.00 Capital Related - Bldg. &

Fixtures

0 0 0 1.00

2.00 Capital Related - Movable

Equipment

0 0 0 2.00

3.00 Plant Operation & Maintenance 0 0 0 0 0 0 3.00

4.00 Transportation 0 0 0 0 0 0 4.00

5.00 Administrative and General 158,594 134,029 7,314 516 107,690 408,143 5.00

HHA REIMBURSABLE SERVICES

6.00 Skilled Nursing Care 516,904 0 0 0 0 516,904 6.00

7.00 Physical Therapy 262,810 0 0 0 0 262,810 7.00

8.00 Occupational Therapy 42,281 0 0 0 0 42,281 8.00

9.00 Speech Pathology 37,865 0 0 0 0 37,865 9.00

10.00 Medical Social Services 9,099 0 0 0 0 9,099 10.00

11.00 Home Health Aide 4,378 0 0 0 0 4,378 11.00

12.00 Supplies (see instructions) 0 0 0 0 19,156 19,156 12.00

13.00 Drugs 0 0 0 0 9,058 9,058 13.00

14.00 DME 0 0 0 0 0 0 14.00

HHA NONREIMBURSABLE SERVICES

15.00 Home Dialysis Aide Services 0 0 0 0 0 0 15.00

16.00 Respiratory Therapy 0 0 0 0 0 0 16.00

17.00 Private Duty Nursing 0 0 0 0 0 0 17.00

18.00 Clinic 0 0 0 0 0 0 18.00

19.00 Health Promotion Activities 0 0 0 0 0 0 19.00

20.00 Day Care Program 0 0 0 0 0 0 20.00

21.00 Home Delivered Meals Program 0 0 0 0 0 0 21.00

22.00 Homemaker Service 0 0 0 0 0 0 22.00

23.00 All Others (specify) 0 0 0 0 0 0 23.00

24.00 Total (sum of lines 1-23) 1,031,931 134,029 7,314 516 135,904 1,309,694 24.00

Reclassificat

ion

Reclassified

Trial Balance

(col. 6 +

col.7)

Adjustments Net Expenses

for

Allocation

(col. 8 +

col. 9)

7.00 8.00 9.00 10.00



Fixtures

0 0 0 0 1.00


Equipment

0 0 0 0 2.00

3.00 Plant Operation & Maintenance 0 0 0 0 3.00

4.00 Transportation 0 0 0 0 4.00

5.00 Administrative and General -94,805 313,338 -1,164 312,174 5.00


6.00 Skilled Nursing Care 71,531 588,435 0 588,435 6.00

7.00 Physical Therapy 35,362 298,172 0 298,172 7.00

8.00 Occupational Therapy 5,718 47,999 0 47,999 8.00

9.00 Speech Pathology 5,190 43,055 0 43,055 9.00

10.00 Medical Social Services 1,211 10,310 0 10,310 10.00

11.00 Home Health Aide 661 5,039 0 5,039 11.00

12.00 Supplies (see instructions) 0 19,156 0 19,156 12.00

13.00 Drugs 0 9,058 0 9,058 13.00

14.00 DME 0 0 0 0 14.00


15.00 Home Dialysis Aide Services 0 0 0 0 15.00

16.00 Respiratory Therapy 0 0 0 0 16.00

17.00 Private Duty Nursing 0 0 0 0 17.00

18.00 Clinic 0 0 0 0 18.00

19.00 Health Promotion Activities 0 0 0 0 19.00

20.00 Day Care Program 0 0 0 0 20.00

21.00 Home Delivered Meals Program 0 0 0 0 21.00

22.00 Homemaker Service 0 0 0 0 22.00

23.00 All Others (specify) 0 0 0 0 23.00

24.00 Total (sum of lines 1-23) 24,868 1,334,562 -1,164 1,333,398 24.00


Column, 6 line 24 should agree with the Worksheet A, column 3, line 101, or subscript as applicable.

MCRIF32 - 8.8.159.0 171 | Page


Date/Time Prepared:

Worksheet H-1

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

HHA CCN: 267121

COST ALLOCATION - HHA GENERAL SERVICE COST

Home Health

Agency I

PPS

Capital Related Costs

Net Expenses

for Cost

Allocation

(from Wkst.

H, col. 10)

Bldgs &

Fixtures

Movable

Equipment

Plant

Operation &

Maintenance

Transportatio

n

Subtotal

(cols. 0-4)

0 1.00 2.00 3.00 4.00 4A.00



Fixtures

0 0 0 1.00


Equipment

0 0 0 2.00

3.00 Plant Operation & Maintenance 0 0 0 0 0 3.00

4.00 Transportation 0 0 0 0 0 4.00

5.00 Administrative and General 312,174 0 0 0 0 312,174 5.00


6.00 Skilled Nursing Care 588,435 0 0 0 0 588,435 6.00

7.00 Physical Therapy 298,172 0 0 0 0 298,172 7.00

8.00 Occupational Therapy 47,999 0 0 0 0 47,999 8.00

9.00 Speech Pathology 43,055 0 0 0 0 43,055 9.00

10.00 Medical Social Services 10,310 0 0 0 0 10,310 10.00

11.00 Home Health Aide 5,039 0 0 0 0 5,039 11.00

12.00 Supplies (see instructions) 19,156 0 0 0 0 19,156 12.00

13.00 Drugs 9,058 0 0 0 9,058 13.00

14.00 DME 0 0 0 0 0 0 14.00





18.00 Clinic 0 0 0 0 0 0 18.00


20.00 Day Care Program 0 0 0 0 0 0 20.00




24.00 Total (sum of lines 1-23) 1,333,398 0 0 0 0 1,333,398 24.00

Administrativ

e & General

Total (cols.

4A + 5)

5.00 6.00



Fixtures

1.00


Equipment

2.00

3.00 Plant Operation & Maintenance 3.00

4.00 Transportation 4.00

5.00 Administrative and General 312,174 5.00


6.00 Skilled Nursing Care 179,876 768,311 6.00

7.00 Physical Therapy 91,147 389,319 7.00

8.00 Occupational Therapy 14,673 62,672 8.00

9.00 Speech Pathology 13,161 56,216 9.00

10.00 Medical Social Services 3,152 13,462 10.00

11.00 Home Health Aide 1,540 6,579 11.00

12.00 Supplies (see instructions) 5,856 25,012 12.00

13.00 Drugs 2,769 11,827 13.00

14.00 DME 0 0 14.00


15.00 Home Dialysis Aide Services 0 0 15.00

16.00 Respiratory Therapy 0 0 16.00

17.00 Private Duty Nursing 0 0 17.00

18.00 Clinic 0 0 18.00

19.00 Health Promotion Activities 0 0 19.00

20.00 Day Care Program 0 0 20.00

21.00 Home Delivered Meals Program 0 0 21.00

22.00 Homemaker Service 0 0 22.00

23.00 All Others (specify) 0 0 23.00

24.00 Total (sum of lines 1-23) 1,333,398 24.00


MCRIF32 - 8.8.159.0 172 | Page


Date/Time Prepared:

Worksheet H-1

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

HHA CCN: 267121

COST ALLOCATION - HHA STATISTICAL BASIS

Home Health

Agency I

PPS

Capital Related Costs

Bldgs &

Fixtures

(SQUARE FEET)

Movable

Equipment

(DOLLAR

VALUE)

Plant

Operation &

Maintenance

(SQUARE FEET)

Transportatio

n (MILEAGE)

Reconciliatio

n

Administrativ

e & General

(ACCUM. COST)

1.00 2.00 3.00 4.00 5A.00 5.00



Fixtures

0 0 1.00


Equipment

0 0 2.00

3.00 Plant Operation & Maintenance 0 0 0 0 3.00

4.00 Transportation (see

instructions)

0 0 0 0 4.00

5.00 Administrative and General 0 0 0 0 -312,174 1,021,224 5.00


6.00 Skilled Nursing Care 0 0 0 0 0 588,435 6.00

7.00 Physical Therapy 0 0 0 0 0 298,172 7.00

8.00 Occupational Therapy 0 0 0 0 0 47,999 8.00

9.00 Speech Pathology 0 0 0 0 0 43,055 9.00

10.00 Medical Social Services 0 0 0 0 0 10,310 10.00

11.00 Home Health Aide 0 0 0 0 0 5,039 11.00

12.00 Supplies (see instructions) 0 0 0 0 0 19,156 12.00

13.00 Drugs 0 0 0 0 9,058 13.00

14.00 DME 0 0 0 0 0 0 14.00





18.00 Clinic 0 0 0 0 0 0 18.00


20.00 Day Care Program 0 0 0 0 0 0 20.00




24.00 Total (sum of lines 1-23) 0 0 0 0 -312,174 1,021,224 24.00

25.00 Cost To Be Allocated (per

Worksheet H-1, Part I)

0 0 0 0 312,174 25.00

26.00 Unit Cost Multiplier 0.000000 0.000000 0.000000 0.000000 0.305686 26.00


MCRIF32 - 8.8.159.0 173 | Page


Date/Time Prepared:

Worksheet H-2

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

HHA CCN: 267121

ALLOCATION OF GENERAL SERVICE COSTS TO HHA COST CENTERS

Home Health

Agency I

PPS

CAPITAL

RELATED COSTS

Cost Center Description HHA Trial

Balance (1)


CSTS-BLDGS &

FIX #2

NEW CAP-REL

CSTS-BLDGS &

FIX #3

NEW CAP-REL

CSTS-BLDGS &

FIX #4

NEW CAP-REL

CSTS-BLDGS &

FIX #5

0 1.00 1.01 1.02 1.03 1.04

1.00 Administrative and General 0 0 0 0 0 0 1.00

2.00 Skilled Nursing Care 768,311 0 0 0 0 0 2.00

3.00 Physical Therapy 389,319 0 0 0 0 0 3.00

4.00 Occupational Therapy 62,672 0 0 0 0 0 4.00

5.00 Speech Pathology 56,216 0 0 0 0 0 5.00

6.00 Medical Social Services 13,462 0 0 0 0 0 6.00

7.00 Home Health Aide 6,579 0 0 0 0 0 7.00

8.00 Supplies (see instructions) 25,012 0 0 0 0 0 8.00

9.00 Drugs 11,827 0 0 0 0 0 9.00

10.00 DME 0 0 0 0 0 0 10.00




14.00 Clinic 0 0 0 0 0 0 14.00


16.00 Day Care Program 0 0 0 0 0 0 16.00




20.00 Total (sum of lines 1-19) (2) 1,333,398 0 0 0 0 0 20.00

21.00 Unit Cost Multiplier: column

26, line 1 divided by the sum

of column 26, line 20 minus

column 26, line 1, rounded to

6 decimal places.

21.00

CAPITAL

RELATED COSTS


CSTS-BLDGS &

FIX #6

NEW CAP-REL

CSTS-BLDGS &

FIX #7

NEW CAP-REL

CSTS-BLDGS &

FIX #8

NEW CAP-REL

CSTS-BLDGS &

FIX #9

NEW CAP-REL

CSTS-BLDGS &

FIX #1

NEW CAP-REL

CSTS-BLDGS &

FIX #1

1.05 1.06 1.07 1.08 1.09 1.10

1.00 Administrative and General 0 0 0 57,051 0 0 1.00

2.00 Skilled Nursing Care 0 0 0 0 0 0 2.00

3.00 Physical Therapy 0 0 0 0 0 0 3.00

4.00 Occupational Therapy 0 0 0 0 0 0 4.00

5.00 Speech Pathology 0 0 0 0 0 0 5.00

6.00 Medical Social Services 0 0 0 0 0 0 6.00

7.00 Home Health Aide 0 0 0 0 0 0 7.00

8.00 Supplies (see instructions) 0 0 0 0 0 0 8.00

9.00 Drugs 0 0 0 0 0 0 9.00

10.00 DME 0 0 0 0 0 0 10.00




14.00 Clinic 0 0 0 0 0 0 14.00


16.00 Day Care Program 0 0 0 0 0 0 16.00




20.00 Total (sum of lines 1-19) (2) 0 0 0 57,051 0 0 20.00





6 decimal places.

21.00


(1) Column 0, line 20 must agree with Wkst. A, column 7, line 101.

(2) Columns 0 through 26, line 20 must agree with the corresponding columns of Wkst. B, Part I, line 101.

MCRIF32 - 8.8.159.0 174 | Page


Date/Time Prepared:

Worksheet H-2

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

HHA CCN: 267121


Home Health

Agency I

PPS

CAPITAL

RELATED COSTS

Cost Center Description MVBLE EQUIP EMPLOYEE

BENEFITS

DEPARTMENT

COMMUNICATION

S

Subtotal DATA

PROCESSING

PURCHASING

RECEIVING AND

STORES

2.00 4.00 5.01 5A.01 5.02 5.03

1.00 Administrative and General 7,334 14,168 8,147 86,700 5,013 2,976 1.00

2.00 Skilled Nursing Care 0 39,919 0 808,230 46,731 0 2.00

3.00 Physical Therapy 0 20,296 0 409,615 23,684 0 3.00

4.00 Occupational Therapy 0 3,265 0 65,937 3,812 0 4.00

5.00 Speech Pathology 0 2,924 0 59,140 3,419 0 5.00

6.00 Medical Social Services 0 703 0 14,165 819 0 6.00

7.00 Home Health Aide 0 338 0 6,917 400 0 7.00

8.00 Supplies (see instructions) 0 0 0 25,012 1,446 0 8.00

9.00 Drugs 0 0 0 11,827 684 0 9.00

10.00 DME 0 0 0 0 0 0 10.00




14.00 Clinic 0 0 0 0 0 0 14.00


16.00 Day Care Program 0 0 0 0 0 0 16.00




20.00 Total (sum of lines 1-19) (2) 7,334 81,613 8,147 1,487,543 86,008 2,976 20.00





6 decimal places.

0.000000 21.00

Cost Center Description ADMITTING CASHIERING/AC

COUNTS

RECEIVABLE

Subtotal OTHER

ADMINISTRATIV

E & GENERAL

MAINTENANCE &

REPAIRS

OPERATION OF

PLANT

5.04 5.05 5A.05 5.06 6.00 7.00

1.00 Administrative and General 5,136 7,687 107,512 16,639 18,191 45,625 1.00

2.00 Skilled Nursing Care 0 0 854,961 132,316 0 0 2.00

3.00 Physical Therapy 0 0 433,299 67,058 0 0 3.00

4.00 Occupational Therapy 0 0 69,749 10,794 0 0 4.00

5.00 Speech Pathology 0 0 62,559 9,682 0 0 5.00

6.00 Medical Social Services 0 0 14,984 2,319 0 0 6.00

7.00 Home Health Aide 0 0 7,317 1,132 0 0 7.00

8.00 Supplies (see instructions) 0 0 26,458 4,095 0 0 8.00

9.00 Drugs 0 0 12,511 1,936 0 0 9.00

10.00 DME 0 0 0 0 0 0 10.00




14.00 Clinic 0 0 0 0 0 0 14.00


16.00 Day Care Program 0 0 0 0 0 0 16.00




20.00 Total (sum of lines 1-19) (2) 5,136 7,687 1,589,350 245,971 18,191 45,625 20.00





6 decimal places.

0.000000 21.00




MCRIF32 - 8.8.159.0 175 | Page


Date/Time Prepared:

Worksheet H-2

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

HHA CCN: 267121


Home Health

Agency I

PPS

Cost Center Description LAUNDRY &

LINEN SERVICE

HOUSEKEEPING DIETARY CAFETERIA MAINTENANCE

OF PERSONNEL

NURSING

ADMINISTRATIO

N

8.00 9.00 10.00 11.00 12.00 13.00

1.00 Administrative and General 0 27,121 0 0 0 229,976 1.00






7.00 Home Health Aide 0 0 0 0 0 0 7.00


9.00 Drugs 0 0 0 0 0 0 9.00

10.00 DME 0 0 0 0 0 0 10.00




14.00 Clinic 0 0 0 0 0 0 14.00


16.00 Day Care Program 0 0 0 0 0 0 16.00




20.00 Total (sum of lines 1-19) (2) 0 27,121 0 0 0 229,976 20.00





6 decimal places.

21.00


SERVICES &

SUPPLY

PHARMACY MEDICAL

RECORDS &

LIBRARY

SOCIAL

SERVICE

NONPHYSICIAN

ANESTHETISTS

NURSING

SCHOOL

14.00 15.00 16.00 17.00 19.00 20.00







7.00 Home Health Aide 0 0 0 0 0 0 7.00


9.00 Drugs 0 0 0 0 0 0 9.00

10.00 DME 0 0 0 0 0 0 10.00




14.00 Clinic 0 0 0 0 0 0 14.00


16.00 Day Care Program 0 0 0 0 0 0 16.00




20.00 Total (sum of lines 1-19) (2) 1,388 0 0 0 0 13,636 20.00





6 decimal places.

21.00




MCRIF32 - 8.8.159.0 176 | Page


Date/Time Prepared:

Worksheet H-2

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

HHA CCN: 267121


Home Health

Agency I

PPS

INTERNS & RESIDENTS


MEDICAL

TECHNOLOGY

SCHOOL OF

SURGICAL

TECHNOLOGY

SCHOOL OF

RADIOLOGICAL

TECHNOLO

SERVICES-SALA

RY & FRINGES

APPRV

SERVICES-OTHE

R PRGM COSTS

APPRV

PARAMEDICAL

EDUCATION

PROGRAM

20.01 20.02 20.03 21.00 22.00 23.00







7.00 Home Health Aide 0 0 0 0 0 0 7.00


9.00 Drugs 0 0 0 0 0 0 9.00

10.00 DME 0 0 0 0 0 0 10.00




14.00 Clinic 0 0 0 0 0 0 14.00


16.00 Day Care Program 0 0 0 0 0 0 16.00




20.00 Total (sum of lines 1-19) (2) 0 0 0 0 0 0 20.00





6 decimal places.

21.00

Cost Center Description Subtotal Intern &

Residents

Cost & Post

Stepdown

Adjustments

Subtotal Allocated HHA

A&G (see Part

II)

Total HHA

Costs

24.00 25.00 26.00 27.00 28.00

1.00 Administrative and General 460,088 0 460,088 1.00

2.00 Skilled Nursing Care 987,277 0 987,277 265,453 1,252,730 2.00

3.00 Physical Therapy 500,357 0 500,357 134,532 634,889 3.00

4.00 Occupational Therapy 80,543 0 80,543 21,656 102,199 4.00

5.00 Speech Pathology 72,241 0 72,241 19,424 91,665 5.00

6.00 Medical Social Services 17,303 0 17,303 4,652 21,955 6.00

7.00 Home Health Aide 8,449 0 8,449 2,272 10,721 7.00

8.00 Supplies (see instructions) 30,553 0 30,553 8,215 38,768 8.00

9.00 Drugs 14,447 0 14,447 3,884 18,331 9.00

10.00 DME 0 0 0 0 0 10.00

11.00 Home Dialysis Aide Services 0 0 0 0 0 11.00

12.00 Respiratory Therapy 0 0 0 0 0 12.00

13.00 Private Duty Nursing 0 0 0 0 0 13.00

14.00 Clinic 0 0 0 0 0 14.00

15.00 Health Promotion Activities 0 0 0 0 0 15.00

16.00 Day Care Program 0 0 0 0 0 16.00

17.00 Home Delivered Meals Program 0 0 0 0 0 17.00

18.00 Homemaker Service 0 0 0 0 0 18.00

19.00 All Others (specify) 0 0 0 0 0 19.00

20.00 Total (sum of lines 1-19) (2) 2,171,258 0 2,171,258 460,088 2,171,258 20.00





6 decimal places.

0.268873 21.00




MCRIF32 - 8.8.159.0 177 | Page


Date/Time Prepared:

Worksheet H-2

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

HHA CCN: 267121

ALLOCATION OF GENERAL SERVICE COSTS TO HHA COST CENTERS STATISTICAL

BASIS

Home Health

Agency I

PPS

CAPITAL

RELATED COSTS


(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #2

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #3

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #4

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #5

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #6

(SQUARE FEET)

1.00 1.01 1.02 1.03 1.04 1.05







7.00 Home Health Aide 0 0 0 0 0 0 7.00


9.00 Drugs 0 0 0 0 0 0 9.00

10.00 DME 0 0 0 0 0 0 10.00




14.00 Clinic 0 0 0 0 0 0 14.00


16.00 Day Care Program 0 0 0 0 0 0 16.00




20.00 Total (sum of lines 1-19) 0 0 0 0 0 0 20.00

21.00 Total cost to be allocated 0 0 0 0 0 0 21.00

22.00 Unit cost multiplier 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 22.00

CAPITAL

RELATED COSTS


CSTS-BLDGS &

FIX #7

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #8

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #9

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #1

(SQUARE FEE

T)

NEW CAP-REL

CSTS-BLDGS &

FIX #1

(SQUARE FEE

T)

MVBLE EQUIP

(DIRECT COS

TS)

1.06 1.07 1.08 1.09 1.10 2.00

1.00 Administrative and General 0 0 3,286 0 0 7,404 1.00






7.00 Home Health Aide 0 0 0 0 0 0 7.00


9.00 Drugs 0 0 0 0 0 0 9.00

10.00 DME 0 0 0 0 0 0 10.00




14.00 Clinic 0 0 0 0 0 0 14.00


16.00 Day Care Program 0 0 0 0 0 0 16.00




20.00 Total (sum of lines 1-19) 0 0 3,286 0 0 7,404 20.00

21.00 Total cost to be allocated 0 0 57,051 0 0 7,334 21.00



MCRIF32 - 8.8.159.0 178 | Page


Date/Time Prepared:

Worksheet H-2

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

HHA CCN: 267121


BASIS

Home Health

Agency I

PPS

Cost Center Description EMPLOYEE

BENEFITS

DEPARTMENT

(GROSS

SALARIES)

COMMUNICATION

S

(NONPATIENT)

Reconciliatio

n

DATA

PROCESSING

(ACCUM. COST)

PURCHASING

RECEIVING AND

STORES

(SUPPLY COS

TS)

ADMITTING

(GROSS REVE

NUES)

4.00 5.01 5A.02 5.02 5.03 5.04

1.00 Administrative and General 183,462 33 0 86,700 12,314 1,426,971 1.00

2.00 Skilled Nursing Care 516,904 0 0 808,230 0 0 2.00

3.00 Physical Therapy 262,810 0 0 409,615 0 0 3.00

4.00 Occupational Therapy 42,281 0 0 65,937 0 0 4.00

5.00 Speech Pathology 37,865 0 0 59,140 0 0 5.00

6.00 Medical Social Services 9,099 0 0 14,165 0 0 6.00

7.00 Home Health Aide 4,378 0 0 6,917 0 0 7.00

8.00 Supplies (see instructions) 0 0 0 25,012 0 0 8.00

9.00 Drugs 0 0 0 11,827 0 0 9.00

10.00 DME 0 0 0 0 0 0 10.00




14.00 Clinic 0 0 0 0 0 0 14.00


16.00 Day Care Program 0 0 0 0 0 0 16.00




20.00 Total (sum of lines 1-19) 1,056,799 33 1,487,543 12,314 1,426,971 20.00

21.00 Total cost to be allocated 81,613 8,147 86,008 2,976 5,136 21.00

22.00 Unit cost multiplier 0.077227 246.878788 0.057819 0.241676 0.003599 22.00

Cost Center Description CASHIERING/AC

COUNTS

RECEIVABLE

(GROSS REVE

NUES)

Reconciliatio

n

OTHER

ADMINISTRATIV

E & GENERAL

(ACCUM. COST)

MAINTENANCE &

REPAIRS

(REQUISITIO)

OPERATION OF

PLANT

(SQUARE FEET)

LAUNDRY &

LINEN SERVICE

(POUNDS OF

LAUNDRY)

5.05 5A.06 5.06 6.00 7.00 8.00

1.00 Administrative and General 1,426,971 0 107,512 41 3,286 0 1.00

2.00 Skilled Nursing Care 0 0 854,961 0 0 0 2.00

3.00 Physical Therapy 0 0 433,299 0 0 0 3.00

4.00 Occupational Therapy 0 0 69,749 0 0 0 4.00

5.00 Speech Pathology 0 0 62,559 0 0 0 5.00

6.00 Medical Social Services 0 0 14,984 0 0 0 6.00

7.00 Home Health Aide 0 0 7,317 0 0 0 7.00

8.00 Supplies (see instructions) 0 0 26,458 0 0 0 8.00

9.00 Drugs 0 0 12,511 0 0 0 9.00

10.00 DME 0 0 0 0 0 0 10.00




14.00 Clinic 0 0 0 0 0 0 14.00


16.00 Day Care Program 0 0 0 0 0 0 16.00




20.00 Total (sum of lines 1-19) 1,426,971 1,589,350 41 3,286 0 20.00

21.00 Total cost to be allocated 7,687 245,971 18,191 45,625 0 21.00



MCRIF32 - 8.8.159.0 179 | Page


Date/Time Prepared:

Worksheet H-2

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

HHA CCN: 267121


BASIS

Home Health

Agency I

PPS

Cost Center Description HOUSEKEEPING

(SQUARE FEET)

DIETARY

(MEALS

SERVED)

CAFETERIA

(MEALS

SERVED)

MAINTENANCE

OF PERSONNEL

(NUMBER

HOUSED)

NURSING

ADMINISTRATIO

N

(FTES SERV

ICE)

CENTRAL

SERVICES &

SUPPLY

(SUPPLY COS

TS)

9.00 10.00 11.00 12.00 13.00 14.00







7.00 Home Health Aide 0 0 0 0 0 0 7.00


9.00 Drugs 0 0 0 0 0 0 9.00

10.00 DME 0 0 0 0 0 0 10.00




14.00 Clinic 0 0 0 0 0 0 14.00


16.00 Day Care Program 0 0 0 0 0 0 16.00




20.00 Total (sum of lines 1-19) 3,286 0 0 0 15 19,156 20.00

21.00 Total cost to be allocated 27,121 0 0 0 229,976 1,388 21.00

22.00 Unit cost multiplier 8.253500 0.000000 0.000000 0.000000 15,331.733333 0.072458 22.00


(COSTED

REQUIS.)

MEDICAL

RECORDS &

LIBRARY

(TIME SPENT)

SOCIAL

SERVICE

(TIME SPENT)

NONPHYSICIAN

ANESTHETISTS

(ASSIGNED

TIME)

NURSING

SCHOOL

(ASSIGNED

TIME)

SCHOOL OF

MEDICAL

TECHNOLOGY

(TIME SPENT)

15.00 16.00 17.00 19.00 20.00 20.01







7.00 Home Health Aide 0 0 0 0 0 0 7.00


9.00 Drugs 0 0 0 0 0 0 9.00

10.00 DME 0 0 0 0 0 0 10.00




14.00 Clinic 0 0 0 0 0 0 14.00


16.00 Day Care Program 0 0 0 0 0 0 16.00




20.00 Total (sum of lines 1-19) 0 0 0 0 288 0 20.00

21.00 Total cost to be allocated 0 0 0 0 13,636 0 21.00



MCRIF32 - 8.8.159.0 180 | Page


Date/Time Prepared:

Worksheet H-2

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

HHA CCN: 267121


BASIS

Home Health

Agency I

PPS

INTERNS & RESIDENTS


SURGICAL

TECHNOLOGY

(TIME SPENT)

SCHOOL OF

RADIOLOGICAL

TECHNOLO

(TIME SPENT)

SERVICES-SALA

RY & FRINGES

APPRV

(ASSIGNED

TIME)

SERVICES-OTHE

R PRGM COSTS

APPRV

(ASSIGNED

TIME)

PARAMEDICAL

EDUCATION

PROGRAM

(ASSIGNED

TIME)

20.02 20.03 21.00 22.00 23.00

1.00 Administrative and General 0 0 0 0 0 1.00

2.00 Skilled Nursing Care 0 0 0 0 0 2.00

3.00 Physical Therapy 0 0 0 0 0 3.00

4.00 Occupational Therapy 0 0 0 0 0 4.00

5.00 Speech Pathology 0 0 0 0 0 5.00

6.00 Medical Social Services 0 0 0 0 0 6.00

7.00 Home Health Aide 0 0 0 0 0 7.00

8.00 Supplies (see instructions) 0 0 0 0 0 8.00

9.00 Drugs 0 0 0 0 0 9.00

10.00 DME 0 0 0 0 0 10.00

11.00 Home Dialysis Aide Services 0 0 0 0 0 11.00

12.00 Respiratory Therapy 0 0 0 0 0 12.00

13.00 Private Duty Nursing 0 0 0 0 0 13.00

14.00 Clinic 0 0 0 0 0 14.00

15.00 Health Promotion Activities 0 0 0 0 0 15.00

16.00 Day Care Program 0 0 0 0 0 16.00

17.00 Home Delivered Meals Program 0 0 0 0 0 17.00

18.00 Homemaker Service 0 0 0 0 0 18.00

19.00 All Others (specify) 0 0 0 0 0 19.00

20.00 Total (sum of lines 1-19) 0 0 0 0 0 20.00

21.00 Total cost to be allocated 0 0 0 0 0 21.00



MCRIF32 - 8.8.159.0 181 | Page


Date/Time Prepared:

Worksheet H-3

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

HHA CCN: 267121

APPORTIONMENT OF PATIENT SERVICE COSTS

Title XVIII Home Health

Agency I

PPS

Cost Center Description From, Wkst.

H-2, Part I,

col. 28, line

Facility

Costs (from

Wkst. H-2,

Part I)

Shared

Ancillary

Costs (from

Part II)

Total HHA

Costs (cols.

1 + 2)

Total Visits Average Cost

Per Visit

(col. 3 ÷

col. 4)

0 1.00 2.00 3.00 4.00 5.00

PART I - COMPUTATION OF LESSER OF AGGREGATE PROGRAM COST, AGGREGATE OF THE PROGRAM LIMITATION COST, OR BENEFICIARY

COST LIMITATION

Cost Per Visit Computation

1.00 Skilled Nursing Care 2.00 1,252,730 1,252,730 3,525 355.38 1.00

2.00 Physical Therapy 3.00 634,889 0 634,889 2,531 250.85 2.00

3.00 Occupational Therapy 4.00 102,199 0 102,199 364 280.77 3.00

4.00 Speech Pathology 5.00 91,665 0 91,665 62 1,478.47 4.00

5.00 Medical Social Services 6.00 21,955 21,955 60 365.92 5.00

6.00 Home Health Aide 7.00 10,721 10,721 274 39.13 6.00

7.00 Total (sum of lines 1-6) 2,114,159 0 2,114,159 6,816 7.00

Program Visits

Part B

Cost Center Description Cost Limits CBSA No. (1) Part A Not Subject

to

Deductibles &

Coinsurance

Subject to

Deductibles

0 1.00 2.00 3.00 4.00 5.00

Limitation Cost Computation

8.00 Skilled Nursing Care 16020 0 1,306 8.00

8.01 Skilled Nursing Care 50089 0 633 8.01

8.02 Skilled Nursing Care 99926 0 0 8.02

9.00 Physical Therapy 16020 0 1,205 9.00

9.01 Physical Therapy 50089 0 487 9.01

9.02 Physical Therapy 99926 0 0 9.02

10.00 Occupational Therapy 16020 0 188 10.00



11.00 Speech Pathology 16020 0 23 11.00



12.00 Medical Social Services 16020 0 29 12.00



13.00 Home Health Aide 16020 0 95 13.00

13.01 Home Health Aide 50089 0 83 13.01

13.02 Home Health Aide 99926 0 0 13.02

14.00 Total (sum of lines 8-13) 0 4,188 14.00

Cost Center Description From Wkst.

H-2 Part I,

col. 28, line

Facility

Costs (from

Wkst. H-2,

Part I)

Shared

Ancillary

Costs (from

Part II)

Total HHA

Costs (cols.

1 + 2)

Total Charges

(from HHA

Record)

Ratio (col. 3

÷ col. 4)

0 1.00 2.00 3.00 4.00 5.00

Supplies and Drugs Cost Computations

15.00 Cost of Medical Supplies 8.00 38,768 0 38,768 0 0.000000 15.00

16.00 Cost of Drugs 9.00 18,331 0 18,331 0 0.000000 16.00

Program Visits Cost of

Services

Part B Part B

Cost Center Description Part A Not Subject

to

Deductibles &

Coinsurance

Subject to

Deductibles &

Coinsurance

Part A Not Subject

to

Deductibles &

Coinsurance

Subject to

Deductibles &

Coinsurance

6.00 7.00 8.00 9.00 10.00 11.00


COST LIMITATION


1.00 Skilled Nursing Care 0 1,939 0 689,082 1.00

2.00 Physical Therapy 0 1,692 0 424,438 2.00

3.00 Occupational Therapy 0 296 0 83,108 3.00

4.00 Speech Pathology 0 44 0 65,053 4.00

5.00 Medical Social Services 0 39 0 14,271 5.00

6.00 Home Health Aide 0 178 0 6,965 6.00

7.00 Total (sum of lines 1-6) 0 4,188 0 1,282,917 7.00


MCRIF32 - 8.8.159.0 182 | Page


Date/Time Prepared:

Worksheet H-3

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

HHA CCN: 267121



Agency I

PPS


6.00 7.00 8.00 9.00 10.00 11.00


8.00 Skilled Nursing Care 8.00



9.00 Physical Therapy 9.00



10.00 Occupational Therapy 10.00



11.00 Speech Pathology 11.00



12.00 Medical Social Services 12.00



13.00 Home Health Aide 13.00



14.00 Total (sum of lines 8-13) 14.00

Program Covered Charges Cost of

Services

Part B Part B

Cost Center Description Part A Not Subject

to

Deductibles &

Coinsurance

Subject to

Deductibles &

Coinsurance

Part A Not Subject

to

Deductibles &

Coinsurance

Subject to

Deductibles &

Coinsurance

6.00 7.00 8.00 9.00 10.00 11.00

Supplies and Drugs Cost Computations

15.00 Cost of Medical Supplies 0 0 0 0 0 0 15.00

16.00 Cost of Drugs 0 0 0 0 16.00

Cost Center Description Total Program

Cost (sum of

cols. 9-10)

12.00


COST LIMITATION


1.00 Skilled Nursing Care 689,082 1.00

2.00 Physical Therapy 424,438 2.00

3.00 Occupational Therapy 83,108 3.00

4.00 Speech Pathology 65,053 4.00

5.00 Medical Social Services 14,271 5.00

6.00 Home Health Aide 6,965 6.00

7.00 Total (sum of lines 1-6) 1,282,917 7.00


12.00




















14.00 Total (sum of lines 8-13) 14.00


MCRIF32 - 8.8.159.0 183 | Page


Date/Time Prepared:

Worksheet H-3

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

HHA CCN: 267121



Agency I

PPS

Cost Center Description From Wkst. C,

Part I, col.

9, line

Cost to

Charge Ratio

Total HHA

Charge (from

provider

records)

HHA Shared

Ancillary

Costs (col. 1

x col. 2)

Transfer to

Part I as

Indicated

0 1.00 2.00 3.00 4.00

PART II - APPORTIONMENT OF COST OF HHA SERVICES FURNISHED BY SHARED HOSPITAL DEPARTMENTS

1.00 Physical Therapy 66.00 0.241650 0 0 col. 2, line 2.00 1.00

1.01 Physical Therapy 1 66.01 0.305163 0 0 col. 2, line 2.01 1.01

1.02 Physical Therapy 2 66.02 0.000000 0 0 col. 2, line 2.02 1.02

2.00 Occupational Therapy 67.00 0.182238 0 0 col. 2, line 3.00 2.00

3.00 Speech Pathology 68.00 0.157783 0 0 col. 2, line 4.00 3.00

4.00 Cost of Medical Supplies 71.00 0.164812 0 0 col. 2, line 15.00 4.00

5.00 Cost of Drugs 73.00 0.215459 0 0 col. 2, line 16.00 5.00


MCRIF32 - 8.8.159.0 184 | Page


Date/Time Prepared:

Worksheet H-4

Part I-II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

HHA CCN: 267121

CALCULATION OF HHA REIMBURSEMENT SETTLEMENT


Agency I

PPS

Part B

Part A Not Subject

to

Deductibles &

Coinsurance

Subject to

Deductibles &

Coinsurance

1.00 2.00 3.00

PART I - COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES

Reasonable Cost of Part A & Part B Services

1.00 Reasonable cost of services (see instructions) 0 0 0 1.00

2.00 Total charges 0 0 0 2.00

Customary Charges

3.00 Amount actually collected from patients liable for payment for services

on a charge basis (from your records)

0 0 0 3.00

4.00 Amount that would have been realized from patients liable for payment

for services on a charge basis had such payment been made in accordance

with 42 CFR §413.13(b)

0 0 0 4.00

5.00 Ratio of line 3 to line 4 (not to exceed 1.000000) 0.000000 0.000000 0.000000 5.00

6.00 Total customary charges (see instructions) 0 0 0 6.00

7.00 Excess of total customary charges over total reasonable cost (complete

only if line 6 exceeds line 1)

0 0 0 7.00

8.00 Excess of reasonable cost over customary charges (complete only if line

1 exceeds line 6)

0 0 0 8.00

9.00 Primary payer amounts 0 0 0 9.00

Part A

Services

Part B

Services

1.00 2.00

PART II - COMPUTATION OF HHA REIMBURSEMENT SETTLEMENT

10.00 Total reasonable cost (see instructions) 0 0 10.00

11.00 Total PPS Reimbursement - Full Episodes without Outliers 0 919,042 11.00

12.00 Total PPS Reimbursement - Full Episodes with Outliers 0 1,894 12.00

13.00 Total PPS Reimbursement - LUPA Episodes 0 12,422 13.00

14.00 Total PPS Reimbursement - PEP Episodes 0 5,150 14.00

15.00 Total PPS Outlier Reimbursement - Full Episodes with Outliers 0 311 15.00

16.00 Total PPS Outlier Reimbursement - PEP Episodes 0 101 16.00

17.00 Total Other Payments 0 0 17.00

18.00 DME Payments 0 0 18.00

19.00 Oxygen Payments 0 0 19.00

20.00 Prosthetic and Orthotic Payments 0 0 20.00

21.00 Part B deductibles billed to Medicare patients (exclude coinsurance) 0 21.00

22.00 Subtotal (sum of lines 10 thru 20 minus line 21) 0 938,920 22.00

23.00 Excess reasonable cost (from line 8) 0 0 23.00

24.00 Subtotal (line 22 minus line 23) 0 938,920 24.00

25.00 Coinsurance billed to program patients (from your records) 0 25.00

26.00 Net cost (line 24 minus line 25) 0 938,920 26.00

27.00 Reimbursable bad debts (from your records) 27.00

28.00 Reimbursable bad debts for dual eligible beneficiaries (see instructions) 28.00

29.00 Total costs - current cost reporting period (line 26 plus line 27) 0 938,920 29.00


30.50 Pioneer ACO demonstration payment adjustment (see instructions) 0 0 30.50

31.00 Subtotal (see instructions) 0 938,920 31.00

31.01 Sequestration adjustment (see instructions) 0 20,438 31.01

32.00 Interim payments (see instructions) 0 918,482 32.00

33.00 Tentative settlement (for contractor use only) 0 0 33.00

34.00 Balance due provider/program (line 31 minus lines 31.01, 32, and 33) 0 0 34.00

35.00 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2,

chapter 1, §115.2

0 0 35.00


MCRIF32 - 8.8.159.0 185 | Page


Date/Time Prepared:

Worksheet H-5

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

HHA CCN: 267121

ANALYSIS OF PAYMENTS TO PROVIDER-BASED HHAs FOR SERVICES RENDERED TO

PROGRAM BENEFICIARIES

Home Health

Agency I

PPS



1.00 2.00 3.00 4.00

1.00 Total interim payments paid to provider 1.000 918,482





2.000 0





3.00

Program to Provider

3.01 3.010 0

3.02 3.020 0

3.03 3.030 0

3.04 3.040 0

3.05 3.050 0

Provider to Program

3.50 3.500 0

3.51 3.510 0

3.52 3.520 0

3.53 3.530 0

3.54 3.540 0


3.50-3.98)

3.990 0


(transfer to Wkst. H-4, Part II, column as appropriate,

line 32)

4.000 918,482





5.00

Program to Provider

5.01 5.010 0

5.02 5.020 0

5.03 5.030 0

Provider to Program

5.50 5.500 0

5.51 5.510 0

5.52 5.520 0


5.50-5.98)

5.990 0



6.00

6.01 SETTLEMENT TO PROVIDER 6.010 0


7.00 Total Medicare program liability (see instructions) 7.000 918,482

Contractor

Number

NPR Date

(Mo/Day/Yr)

0 1.00 2.00



MCRIF32 - 8.8.159.0 186 | Page


Date/Time Prepared:

Worksheet K

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537

ANALYSIS OF PROVIDER-BASED HOSPICE COSTS

Hospice I

Salaries

(from Wkst.

K-1)

Employee

Benefits

(from Wkst.

K-2)

Transportatio

n (see inst.)

Contracted

Services

(from Wkst.

K-3)

Other

1.00 2.00 3.00 4.00 5.00


1.00 Capital Related Costs-Bldg and Fixt. 0 0 1.00

2.00 Capital Related Costs-Movable Equip. 0 0 2.00

3.00 Plant Operation and Maintenance 0 0 0 0 0 3.00

4.00 Transportation - Staff 0 0 0 0 0 4.00

5.00 Volunteer Service Coordination 0 0 0 0 0 5.00

6.00 Administrative and General 178,551 22,233 0 0 109,757 6.00

INPATIENT CARE SERVICE

7.00 Inpatient - General Care 0 0 0 426,050 0 7.00

8.00 Inpatient - Respite Care 0 0 0 0 0 8.00

VISITING SERVICES

9.00 Physician Services 201,178 25,049 0 0 0 9.00

10.00 Nursing Care 551,613 68,683 24,455 0 0 10.00

11.00 Nursing Care-Continuous Home Care 0 0 0 0 0 11.00



14.00 Speech/ Language Pathology 0 0 0 0 0 14.00

15.00 Medical Social Services 81,745 10,178 0 0 0 15.00

16.00 Spiritual Counseling 69,889 8,702 0 0 0 16.00

17.00 Dietary Counseling 0 0 0 0 0 17.00

18.00 Counseling - Other 0 0 0 0 0 18.00

19.00 Home Health Aide and Homemaker 35,084 4,368 0 0 0 19.00

20.00 HH Aide & Homemaker - Cont. Home Care 0 0 0 0 0 20.00

21.00 Other 0 0 0 0 0 21.00

OTHER HOSPICE SERVICE COSTS

22.00 Drugs, Biological and Infusion Therapy 0 0 0 0 15,149 22.00

23.00 Analgesics 0 0 0 0 0 23.00

24.00 Sedatives / Hypnotics 0 0 0 0 0 24.00

25.00 Other - Specify 0 0 0 0 0 25.00

26.00 Durable Medical Equipment/Oxygen 0 0 0 0 180,159 26.00

27.00 Patient Transportation 0 0 0 0 0 27.00

28.00 Imaging Services 0 0 0 0 0 28.00

29.00 Labs and Diagnostics 0 0 0 0 0 29.00

30.00 Medical Supplies 0 0 0 0 0 30.00

31.00 Outpatient Services (including E/R Dept.) 0 0 0 0 0 31.00

32.00 Radiation Therapy 0 0 0 0 0 32.00

33.00 Chemotherapy 0 0 0 0 0 33.00

34.00 Other 0 0 0 0 0 34.00

HOSPICE NONREIMBURSABLE SERVICE

35.00 Bereavement Program Costs 0 0 0 0 0 35.00

36.00 Volunteer Program Costs 0 0 0 0 0 36.00

37.00 Fundraising 0 0 0 0 0 37.00

38.00 Other Program Costs 0 0 0 0 0 38.00

39.00 Total (sum of lines 1 thru 38) 1,118,060 139,213 24,455 426,050 305,065 39.00


MCRIF32 - 8.8.159.0 187 | Page


Date/Time Prepared:

Worksheet K

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537

ANALYSIS OF PROVIDER-BASED HOSPICE COSTS

Hospice I

Total (cols.

1-5)

Reclassificat

ion

Subtotal

(col. 6 ±

col. 7)

Adjustments Total (col. 8

± col. 9)

6.00 7.00 8.00 9.00 10.00


1.00 Capital Related Costs-Bldg and Fixt. 0 0 0 0 0 1.00

2.00 Capital Related Costs-Movable Equip. 0 0 0 0 0 2.00




6.00 Administrative and General 310,541 27,282 337,823 -32 337,791 6.00


7.00 Inpatient - General Care 426,050 0 426,050 0 426,050 7.00


VISITING SERVICES

9.00 Physician Services 226,227 4,943 231,170 -223,768 7,402 9.00

10.00 Nursing Care 644,751 49,892 694,643 0 694,643 10.00





15.00 Medical Social Services 91,923 -134,519 -42,596 0 -42,596 15.00

16.00 Spiritual Counseling 78,591 0 78,591 0 78,591 16.00



19.00 Home Health Aide and Homemaker 39,452 2,031 41,483 0 41,483 19.00


21.00 Other 0 0 0 0 0 21.00


22.00 Drugs, Biological and Infusion Therapy 15,149 0 15,149 0 15,149 22.00

23.00 Analgesics 0 0 0 0 0 23.00


25.00 Other - Specify 0 0 0 0 0 25.00

26.00 Durable Medical Equipment/Oxygen 180,159 0 180,159 0 180,159 26.00







33.00 Chemotherapy 0 0 0 0 0 33.00

34.00 Other 0 0 0 0 0 34.00


35.00 Bereavement Program Costs 0 75,239 75,239 0 75,239 35.00


37.00 Fundraising 0 0 0 0 0 37.00


39.00 Total (sum of lines 1 thru 38) 2,012,843 24,868 2,037,711 -223,800 1,813,911 39.00


MCRIF32 - 8.8.159.0 188 | Page


Date/Time Prepared:

Worksheet K-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537

HOSPICE COMPENSATION ANALYSIS SALARIES AND WAGES

Hospice I

Administrator Director Social

Services

Supervisors Nurses

1.00 2.00 3.00 4.00 5.00


1.00 Capital Related Costs-Bldg and Fixt. 1.00

2.00 Capital Related Costs-Movable Equip. 2.00




6.00 Administrative and General 0 71,972 0 0 0 6.00


7.00 Inpatient - General Care 0 0 0 0 0 7.00


VISITING SERVICES

9.00 Physician Services 0 0 0 0 0 9.00

10.00 Nursing Care 0 0 0 0 551,613 10.00





15.00 Medical Social Services 0 0 81,745 0 0 15.00

16.00 Spiritual Counseling 0 0 0 0 0 16.00



19.00 Home Health Aide and Homemaker 0 0 0 0 0 19.00


21.00 Other 0 0 0 0 0 21.00


22.00 Drugs, Biological and Infusion Therapy 22.00

23.00 Analgesics 23.00

24.00 Sedatives / Hypnotics 24.00

25.00 Other - Specify 25.00

26.00 Durable Medical Equipment/Oxygen 26.00







33.00 Chemotherapy 0 0 0 0 0 33.00

34.00 Other 0 0 0 0 0 34.00




37.00 Fundraising 0 0 0 0 0 37.00


39.00 Total (sum of lines 1 thru 38) 0 71,972 81,745 0 551,613 39.00


MCRIF32 - 8.8.159.0 189 | Page


Date/Time Prepared:

Worksheet K-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537

HOSPICE COMPENSATION ANALYSIS SALARIES AND WAGES

Hospice I

Total

Therapists

Aides All-Other Total (1)

6.00 7.00 8.00 9.00




3.00 Plant Operation and Maintenance 0 0 0 3.00

4.00 Transportation - Staff 0 0 0 4.00

5.00 Volunteer Service Coordination 0 0 0 5.00

6.00 Administrative and General 0 106,579 178,551 6.00


7.00 Inpatient - General Care 0 0 0 7.00

8.00 Inpatient - Respite Care 0 0 0 8.00

VISITING SERVICES

9.00 Physician Services 0 201,178 201,178 9.00

10.00 Nursing Care 0 0 551,613 10.00

11.00 Nursing Care-Continuous Home Care 0 0 0 11.00

12.00 Physical Therapy 0 0 0 0 12.00

13.00 Occupational Therapy 0 0 0 0 13.00

14.00 Speech/ Language Pathology 0 0 0 0 14.00

15.00 Medical Social Services 0 0 81,745 15.00

16.00 Spiritual Counseling 0 69,889 69,889 16.00

17.00 Dietary Counseling 0 0 0 17.00

18.00 Counseling - Other 0 0 0 18.00

19.00 Home Health Aide and Homemaker 35,084 0 35,084 19.00

20.00 HH Aide & Homemaker - Cont. Home Care 0 0 0 20.00

21.00 Other 0 0 0 21.00







27.00 Patient Transportation 0 0 0 27.00

28.00 Imaging Services 0 0 0 28.00

29.00 Labs and Diagnostics 0 0 0 29.00

30.00 Medical Supplies 0 0 0 30.00

31.00 Outpatient Services (including E/R Dept.) 0 0 0 31.00

32.00 Radiation Therapy 0 0 0 32.00

33.00 Chemotherapy 0 0 0 33.00

34.00 Other 0 0 0 34.00


35.00 Bereavement Program Costs 0 0 0 35.00

36.00 Volunteer Program Costs 0 0 0 36.00

37.00 Fundraising 0 0 0 37.00

38.00 Other Program Costs 0 0 0 38.00

39.00 Total (sum of lines 1 thru 38) 0 35,084 377,646 1,118,060 39.00


MCRIF32 - 8.8.159.0 190 | Page


Date/Time Prepared:

Worksheet K-2

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537

HOSPICE COMPENSATION ANALYSIS EMPLOYEE BENEFITS (PAYROLL RELATED)

Hospice I


Services

Supervisors Nurses

1.00 2.00 3.00 4.00 5.00







6.00 Administrative and General 0 8,963 0 0 0 6.00




VISITING SERVICES


10.00 Nursing Care 0 0 0 0 68,683 10.00











21.00 Other 0 0 0 0 0 21.00













33.00 Chemotherapy 0 0 0 0 0 33.00

34.00 Other 0 0 0 0 0 34.00




37.00 Fundraising 0 0 0 0 0 37.00


39.00 Total (sum of lines 1 thru 38) 0 8,963 10,178 0 68,683 39.00


MCRIF32 - 8.8.159.0 191 | Page


Date/Time Prepared:

Worksheet K-2

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537

HOSPICE COMPENSATION ANALYSIS EMPLOYEE BENEFITS (PAYROLL RELATED)

Hospice I

Total

Therapists


6.00 7.00 8.00 9.00









7.00 Inpatient - General Care 0 0 0 7.00


VISITING SERVICES

9.00 Physician Services 0 25,049 25,049 9.00

10.00 Nursing Care 0 0 68,683 10.00





15.00 Medical Social Services 0 0 10,178 15.00

16.00 Spiritual Counseling 0 8,702 8,702 16.00



19.00 Home Health Aide and Homemaker 4,368 0 4,368 19.00


21.00 Other 0 0 0 21.00














34.00 Other 0 0 0 34.00




37.00 Fundraising 0 0 0 37.00


39.00 Total (sum of lines 1 thru 38) 0 4,368 47,021 139,213 39.00


MCRIF32 - 8.8.159.0 192 | Page


Date/Time Prepared:

Worksheet K-3

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537

HOSPICE COMPENSATION ANALYSIS CONTRACTED SERVICES/PURCHASED SERVICES

Hospice I


Services

Supervisors Nurses

1.00 2.00 3.00 4.00 5.00









7.00 Inpatient - General Care 0 0 0 0 426,050 7.00


VISITING SERVICES


10.00 Nursing Care 0 0 0 0 0 10.00











21.00 Other 0 0 0 0 0 21.00













33.00 Chemotherapy 0 0 0 0 0 33.00

34.00 Other 0 0 0 0 0 34.00




37.00 Fundraising 0 0 0 0 0 37.00


39.00 Total (sum of lines 1 thru 38) 0 0 0 0 426,050 39.00


MCRIF32 - 8.8.159.0 193 | Page


Date/Time Prepared:

Worksheet K-3

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537

HOSPICE COMPENSATION ANALYSIS CONTRACTED SERVICES/PURCHASED SERVICES

Hospice I

Total

Therapists


6.00 7.00 8.00 9.00







6.00 Administrative and General 0 0 0 6.00


7.00 Inpatient - General Care 0 0 426,050 7.00


VISITING SERVICES

9.00 Physician Services 0 0 0 9.00

10.00 Nursing Care 0 0 0 10.00






16.00 Spiritual Counseling 0 0 0 16.00



19.00 Home Health Aide and Homemaker 0 0 0 19.00


21.00 Other 0 0 0 21.00














34.00 Other 0 0 0 34.00




37.00 Fundraising 0 0 0 37.00


39.00 Total (sum of lines 1 thru 38) 0 0 0 426,050 39.00


MCRIF32 - 8.8.159.0 194 | Page


Date/Time Prepared:

Worksheet K-4

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537

COST ALLOCATION - HOSPICE GENERAL SERVICE COST

Hospice I

CAPITAL RELATED COST

NET EXPENSES

FOR COST

ALLOCATION

BUILDINGS &

FIXTURES

MOVABLE

EQUIPMENT

PLANT

OPERATION &

MAINT.

TRANSPORTATIO

N

0 1.00 2.00 3.00 4.00


1.00 Capital Related Costs-Bldg and Fixt. 0 0 1.00


3.00 Plant Operation and Maintenance 0 0 0 0 3.00



6.00 Administrative and General 337,791 0 0 0 0 6.00


7.00 Inpatient - General Care 426,050 0 0 0 0 7.00


VISITING SERVICES

9.00 Physician Services 7,402 0 0 0 0 9.00

10.00 Nursing Care 694,643 0 0 0 0 10.00





15.00 Medical Social Services -42,596 0 0 0 0 15.00

16.00 Spiritual Counseling 78,591 0 0 0 0 16.00



19.00 Home Health Aide and Homemaker 41,483 0 0 0 0 19.00


21.00 Other 0 0 0 0 0 21.00


22.00 Drugs, Biological and Infusion Therapy 15,149 0 0 0 0 22.00

23.00 Analgesics 0 0 0 0 0 23.00


25.00 Other - Specify 0 0 0 0 0 25.00

26.00 Durable Medical Equipment/Oxygen 180,159 0 0 0 0 26.00







33.00 Chemotherapy 0 0 0 0 0 33.00

34.00 Other 0 0 0 0 0 34.00


35.00 Bereavement Program Costs 75,239 0 0 0 0 35.00


37.00 Fundraising 0 0 0 0 0 37.00


39.00 Total (sum of lines 1 thru 38) 1,813,911 0 0 0 0 39.00


MCRIF32 - 8.8.159.0 195 | Page


Date/Time Prepared:

Worksheet K-4

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537

COST ALLOCATION - HOSPICE GENERAL SERVICE COST

Hospice I

VOLUNTEER

SERVICES

COORDINATOR

SUBTOTAL

(cols. 0 - 5)

ADMINISTRATIV

E & GENERAL

TOTAL (col.

5A ± col. 6)

5.00 5A 6.00 7.00




3.00 Plant Operation and Maintenance 3.00

4.00 Transportation - Staff 4.00

5.00 Volunteer Service Coordination 0 5.00



7.00 Inpatient - General Care 0 426,050 97,496 523,546 7.00

8.00 Inpatient - Respite Care 0 0 0 0 8.00

VISITING SERVICES

9.00 Physician Services 0 7,402 1,694 9,096 9.00

10.00 Nursing Care 0 694,643 158,960 853,603 10.00

11.00 Nursing Care-Continuous Home Care 0 0 0 0 11.00




15.00 Medical Social Services 0 -42,596 -9,748 -52,344 15.00

16.00 Spiritual Counseling 0 78,591 17,985 96,576 16.00

17.00 Dietary Counseling 0 0 0 0 17.00

18.00 Counseling - Other 0 0 0 0 18.00

19.00 Home Health Aide and Homemaker 0 41,483 9,493 50,976 19.00

20.00 HH Aide & Homemaker - Cont. Home Care 0 0 0 0 20.00

21.00 Other 0 0 0 0 21.00


22.00 Drugs, Biological and Infusion Therapy 0 15,149 3,467 18,616 22.00

23.00 Analgesics 0 0 0 0 23.00

24.00 Sedatives / Hypnotics 0 0 0 0 24.00

25.00 Other - Specify 0 0 0 0 25.00

26.00 Durable Medical Equipment/Oxygen 0 180,159 41,227 221,386 26.00

27.00 Patient Transportation 0 0 0 0 27.00

28.00 Imaging Services 0 0 0 0 28.00

29.00 Labs and Diagnostics 0 0 0 0 29.00

30.00 Medical Supplies 0 0 0 0 30.00

31.00 Outpatient Services (including E/R Dept.) 0 0 0 0 31.00

32.00 Radiation Therapy 0 0 0 0 32.00

33.00 Chemotherapy 0 0 0 0 33.00

34.00 Other 0 0 0 0 34.00


35.00 Bereavement Program Costs 0 75,239 17,217 92,456 35.00

36.00 Volunteer Program Costs 0 0 0 0 36.00

37.00 Fundraising 0 0 0 0 37.00

38.00 Other Program Costs 0 0 0 0 38.00

39.00 Total (sum of lines 1 thru 38) 0 1,813,911 1,813,911 39.00


MCRIF32 - 8.8.159.0 196 | Page


Date/Time Prepared:

Worksheet K-4

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537

COST ALLOCATION - STATISTICAL BASIS

Hospice I

CAPITAL RELATED COST

BUILDINGS &

FIXTURES (SQ.

FT.)

MOVABLE

EQUIPMENT ($

VALUE)

PLANT

OPERATION &

MAINT. (SQ.

FT.)

TRANSPORTATIO

N (MILEAGE)

VOLUNTEER

SERVICES

COORDINATOR

(HOURS)

1.00 2.00 3.00 4.00 5.00


1.00 Capital Related Costs-Bldg and Fixt. 0 1.00



4.00 Transportation - Staff 0 0 0 0 4.00






VISITING SERVICES


10.00 Nursing Care 0 0 0 0 0 10.00











21.00 Other 0 0 0 0 0 21.00


22.00 Drugs, Biological and Infusion Therapy 0 0 0 0 0 22.00

23.00 Analgesics 0 0 0 0 0 23.00


25.00 Other - Specify 0 0 0 0 0 25.00

26.00 Durable Medical Equipment/Oxygen 0 0 0 0 0 26.00







33.00 Chemotherapy 0 0 0 0 0 33.00

34.00 Other 0 0 0 0 0 34.00




37.00 Fundraising 0 0 0 0 0 37.00


39.00 Cost to be Allocated (per Wkst. K-4, Part I) 0 0 0 0 0 39.00

40.00 Unit Cost Multiplier 0.000000 0.000000 0.000000 0.000000 0.000000 40.00


MCRIF32 - 8.8.159.0 197 | Page


Date/Time Prepared:

Worksheet K-4

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537

COST ALLOCATION - STATISTICAL BASIS

Hospice I

RECONCILIATIO

N

ADMINISTRATIV

E & GENERAL

(ACC. COST)

6A 6.00


1.00 Capital Related Costs-Bldg and Fixt. 0 1.00

2.00 Capital Related Costs-Movable Equip. 0 2.00

3.00 Plant Operation and Maintenance 0 3.00

4.00 Transportation - Staff 0 4.00

5.00 Volunteer Service Coordination 5.00

6.00 Administrative and General -337,791 1,476,120 6.00


7.00 Inpatient - General Care 0 426,050 7.00

8.00 Inpatient - Respite Care 0 0 8.00

VISITING SERVICES

9.00 Physician Services 0 7,402 9.00

10.00 Nursing Care 0 694,643 10.00

11.00 Nursing Care-Continuous Home Care 0 0 11.00

12.00 Physical Therapy 0 0 12.00

13.00 Occupational Therapy 0 0 13.00

14.00 Speech/ Language Pathology 0 0 14.00

15.00 Medical Social Services 0 -42,596 15.00

16.00 Spiritual Counseling 0 78,591 16.00

17.00 Dietary Counseling 0 0 17.00

18.00 Counseling - Other 0 0 18.00

19.00 Home Health Aide and Homemaker 0 41,483 19.00

20.00 HH Aide & Homemaker - Cont. Home Care 0 0 20.00

21.00 Other 0 0 21.00


22.00 Drugs, Biological and Infusion Therapy 0 15,149 22.00

23.00 Analgesics 0 0 23.00

24.00 Sedatives / Hypnotics 0 0 24.00

25.00 Other - Specify 0 0 25.00

26.00 Durable Medical Equipment/Oxygen 0 180,159 26.00

27.00 Patient Transportation 0 0 27.00

28.00 Imaging Services 0 0 28.00

29.00 Labs and Diagnostics 0 0 29.00

30.00 Medical Supplies 0 0 30.00

31.00 Outpatient Services (including E/R Dept.) 0 0 31.00

32.00 Radiation Therapy 0 0 32.00

33.00 Chemotherapy 0 0 33.00

34.00 Other 0 0 34.00


35.00 Bereavement Program Costs 0 75,239 35.00

36.00 Volunteer Program Costs 0 0 36.00

37.00 Fundraising 0 0 37.00

38.00 Other Program Costs 0 0 38.00

39.00 Cost to be Allocated (per Wkst. K-4, Part I) 337,791 39.00

40.00 Unit Cost Multiplier 0.228837 40.00


MCRIF32 - 8.8.159.0 198 | Page


Date/Time Prepared:

Worksheet K-5

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537

ALLOCATION OF GENERAL SERVICE COSTS TO HOSPICE COST CENTERS

Hospice I


Cost Center Description Hospice Trial

Balance (1)


CSTS-BLDGS &

FIX #2

NEW CAP-REL

CSTS-BLDGS &

FIX #3

NEW CAP-REL

CSTS-BLDGS &

FIX #4

0 1.00 1.01 1.02 1.03

1.00 Administrative and General 0 0 0 0 1.00




5.00 Nursing Care 853,603 0 0 0 0 5.00











16.00 Other 0 0 0 0 0 16.00


18.00 Analgesics 0 0 0 0 0 18.00


20.00 Other - Specify 0 0 0 0 0 20.00








28.00 Chemotherapy 0 0 0 0 0 28.00

29.00 Other 0 0 0 0 0 29.00



32.00 Fundraising 0 0 0 0 0 32.00


34.00 Total (sum of lines 1 thru 33) (2) 1,813,911 0 0 0 0 34.00

35.00 Unit Cost Multiplier (see instructions) 35.00


MCRIF32 - 8.8.159.0 199 | Page


Date/Time Prepared:

Worksheet K-5

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537


Hospice I



CSTS-BLDGS &

FIX #5

NEW CAP-REL

CSTS-BLDGS &

FIX #6

NEW CAP-REL

CSTS-BLDGS &

FIX #7

NEW CAP-REL

CSTS-BLDGS &

FIX #8

NEW CAP-REL

CSTS-BLDGS &

FIX #9

1.04 1.05 1.06 1.07 1.08

1.00 Administrative and General 0 0 0 0 57,051 1.00




5.00 Nursing Care 0 0 0 0 0 5.00











16.00 Other 0 0 0 0 0 16.00


18.00 Analgesics 0 0 0 0 0 18.00


20.00 Other - Specify 0 0 0 0 0 20.00








28.00 Chemotherapy 0 0 0 0 0 28.00

29.00 Other 0 0 0 0 0 29.00



32.00 Fundraising 0 0 0 0 0 32.00


34.00 Total (sum of lines 1 thru 33) (2) 0 0 0 0 57,051 34.00



MCRIF32 - 8.8.159.0 200 | Page


Date/Time Prepared:

Worksheet K-5

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537


Hospice I



CSTS-BLDGS &

FIX #1

NEW CAP-REL

CSTS-BLDGS &

FIX #1


BENEFITS

DEPARTMENT

COMMUNICATION

S

1.09 1.10 2.00 4.00 5.01

1.00 Administrative and General 0 0 321 15,247 9,134 1.00



4.00 Physician Services 0 0 0 15,080 0 4.00

5.00 Nursing Care 0 0 0 41,349 0 5.00





10.00 Medical Social Services 0 0 0 6,128 0 10.00

11.00 Spiritual Counseling 0 0 0 5,239 0 11.00




15.00 HH Aide & Homemaker - Cont. Home Care 0 0 0 2,630 0 15.00

16.00 Other 0 0 0 0 0 16.00


18.00 Analgesics 0 0 0 0 0 18.00


20.00 Other - Specify 0 0 0 0 0 20.00








28.00 Chemotherapy 0 0 0 0 0 28.00

29.00 Other 0 0 0 0 0 29.00

30.00 Bereavement Program Costs 0 0 0 2,127 0 30.00


32.00 Fundraising 0 0 0 465 0 32.00


34.00 Total (sum of lines 1 thru 33) (2) 0 0 321 88,265 9,134 34.00



MCRIF32 - 8.8.159.0 201 | Page


Date/Time Prepared:

Worksheet K-5

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537


Hospice I


PROCESSING

PURCHASING

RECEIVING AND

STORES


COUNTS

RECEIVABLE

5A.01 5.02 5.03 5.04 5.05

1.00 Administrative and General 81,753 4,727 2,479 9,933 14,867 1.00

2.00 Inpatient - General Care 523,546 30,271 0 0 0 2.00



5.00 Nursing Care 894,952 51,745 0 0 0 5.00





10.00 Medical Social Services -46,216 -2,672 0 0 0 10.00





15.00 HH Aide & Homemaker - Cont. Home Care 2,630 152 0 0 0 15.00

16.00 Other 0 0 0 0 0 16.00

17.00 Drugs, Biological and Infusion Therapy 18,616 1,076 0 0 0 17.00

18.00 Analgesics 0 0 0 0 0 18.00


20.00 Other - Specify 0 0 0 0 0 20.00

21.00 Durable Medical Equipment/Oxygen 221,386 12,800 0 0 0 21.00







28.00 Chemotherapy 0 0 0 0 0 28.00

29.00 Other 0 0 0 0 0 29.00

30.00 Bereavement Program Costs 94,583 5,469 0 0 0 30.00


32.00 Fundraising 465 27 0 0 0 32.00


34.00 Total (sum of lines 1 thru 33) (2) 1,968,682 113,827 2,479 9,933 14,867 34.00

35.00 Unit Cost Multiplier (see instructions) 0.000000 35.00


MCRIF32 - 8.8.159.0 202 | Page


Date/Time Prepared:

Worksheet K-5

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537


Hospice I


ADMINISTRATIV

E & GENERAL

MAINTENANCE &

REPAIRS

OPERATION OF

PLANT

LAUNDRY &

LINEN SERVICE

5A.05 5.06 6.00 7.00 8.00

1.00 Administrative and General 113,759 17,606 27,064 45,625 0 1.00

2.00 Inpatient - General Care 553,817 85,710 0 0 0 2.00



5.00 Nursing Care 946,697 146,512 0 0 0 5.00





10.00 Medical Social Services -48,888 -7,566 0 0 0 10.00






16.00 Other 0 0 0 0 0 16.00

17.00 Drugs, Biological and Infusion Therapy 19,692 3,048 0 0 0 17.00

18.00 Analgesics 0 0 0 0 0 18.00


20.00 Other - Specify 0 0 0 0 0 20.00

21.00 Durable Medical Equipment/Oxygen 234,186 36,243 0 0 0 21.00







28.00 Chemotherapy 0 0 0 0 0 28.00

29.00 Other 0 0 0 0 0 29.00

30.00 Bereavement Program Costs 100,052 15,484 0 0 0 30.00


32.00 Fundraising 492 76 0 0 0 32.00


34.00 Total (sum of lines 1 thru 33) (2) 2,109,788 326,515 27,064 45,625 0 34.00



MCRIF32 - 8.8.159.0 203 | Page


Date/Time Prepared:

Worksheet K-5

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537


Hospice I


OF PERSONNEL

NURSING

ADMINISTRATIO

N

9.00 10.00 11.00 12.00 13.00

1.00 Administrative and General 27,121 0 0 0 275,971 1.00




5.00 Nursing Care 0 0 0 0 0 5.00











16.00 Other 0 0 0 0 0 16.00


18.00 Analgesics 0 0 0 0 0 18.00


20.00 Other - Specify 0 0 0 0 0 20.00








28.00 Chemotherapy 0 0 0 0 0 28.00

29.00 Other 0 0 0 0 0 29.00



32.00 Fundraising 0 0 0 0 0 32.00


34.00 Total (sum of lines 1 thru 33) (2) 27,121 0 0 0 275,971 34.00



MCRIF32 - 8.8.159.0 204 | Page


Date/Time Prepared:

Worksheet K-5

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537


Hospice I


SERVICES &

SUPPLY

PHARMACY MEDICAL

RECORDS &

LIBRARY

SOCIAL

SERVICE

NONPHYSICIAN

ANESTHETISTS

14.00 15.00 16.00 17.00 19.00

1.00 Administrative and General 1,071 0 0 0 0 1.00




5.00 Nursing Care 0 0 0 0 0 5.00











16.00 Other 0 0 0 0 0 16.00


18.00 Analgesics 0 0 0 0 0 18.00


20.00 Other - Specify 0 0 0 0 0 20.00








28.00 Chemotherapy 0 0 0 0 0 28.00

29.00 Other 0 0 0 0 0 29.00



32.00 Fundraising 0 0 0 0 0 32.00


34.00 Total (sum of lines 1 thru 33) (2) 1,071 0 0 0 0 34.00



MCRIF32 - 8.8.159.0 205 | Page


Date/Time Prepared:

Worksheet K-5

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537


Hospice I

INTERNS &

RESIDENTS


SCHOOL

SCHOOL OF

MEDICAL

TECHNOLOGY

SCHOOL OF

SURGICAL

TECHNOLOGY

SCHOOL OF

RADIOLOGICAL

TECHNOLO

SERVICES-SALA

RY & FRINGES

APPRV

20.00 20.01 20.02 20.03 21.00





5.00 Nursing Care 24,999 0 0 0 0 5.00











16.00 Other 0 0 0 0 0 16.00


18.00 Analgesics 0 0 0 0 0 18.00


20.00 Other - Specify 0 0 0 0 0 20.00








28.00 Chemotherapy 0 0 0 0 0 28.00

29.00 Other 0 0 0 0 0 29.00



32.00 Fundraising 0 0 0 0 0 32.00


34.00 Total (sum of lines 1 thru 33) (2) 24,999 0 0 0 0 34.00



MCRIF32 - 8.8.159.0 206 | Page


Date/Time Prepared:

Worksheet K-5

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537


Hospice I

INTERNS &

RESIDENTS


R PRGM COSTS

APPRV

PARAMEDICAL

EDUCATION

PROGRAM

Subtotal

(cols. 4A-23)

Intern &

Residents

Cost & Post

Stepdown

Adjustments

Subtotal

(cols. 24 ±

25)

22.00 23.00 24.00 25.00 26.00

1.00 Administrative and General 0 0 508,217 1.00

2.00 Inpatient - General Care 0 0 639,527 0 639,527 2.00


4.00 Physician Services 0 0 29,532 0 29,532 4.00

5.00 Nursing Care 0 0 1,118,208 0 1,118,208 5.00





10.00 Medical Social Services 0 0 -56,454 0 -56,454 10.00

11.00 Spiritual Counseling 0 0 124,370 0 124,370 11.00



14.00 Home Health Aide and Homemaker 0 0 62,268 0 62,268 14.00

15.00 HH Aide & Homemaker - Cont. Home Care 0 0 3,213 0 3,213 15.00

16.00 Other 0 0 0 0 0 16.00

17.00 Drugs, Biological and Infusion Therapy 0 0 22,740 0 22,740 17.00

18.00 Analgesics 0 0 0 0 0 18.00


20.00 Other - Specify 0 0 0 0 0 20.00

21.00 Durable Medical Equipment/Oxygen 0 0 270,429 0 270,429 21.00







28.00 Chemotherapy 0 0 0 0 0 28.00

29.00 Other 0 0 0 0 0 29.00

30.00 Bereavement Program Costs 0 0 115,536 0 115,536 30.00


32.00 Fundraising 0 0 568 0 568 32.00


34.00 Total (sum of lines 1 thru 33) (2) 0 0 2,838,154 0 2,838,154 34.00



MCRIF32 - 8.8.159.0 207 | Page


Date/Time Prepared:

Worksheet K-5

Part I

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537


Hospice I

Cost Center Description Allocated

Hospice A&G

(See Part II)

Total Hospice

Costs (cols.

26 ± 27)

27.00 28.00

1.00 Administrative and General 1.00

2.00 Inpatient - General Care 139,497 779,024 2.00

3.00 Inpatient - Respite Care 0 0 3.00

4.00 Physician Services 6,442 35,974 4.00

5.00 Nursing Care 243,909 1,362,117 5.00

6.00 Nursing Care-Continuous Home Care 0 0 6.00

7.00 Physical Therapy 0 0 7.00

8.00 Occupational Therapy 0 0 8.00

9.00 Speech/ Language Pathology 0 0 9.00

10.00 Medical Social Services -12,314 -68,768 10.00

11.00 Spiritual Counseling 27,128 151,498 11.00

12.00 Dietary Counseling 0 0 12.00

13.00 Counseling - Other 0 0 13.00

14.00 Home Health Aide and Homemaker 13,582 75,850 14.00

15.00 HH Aide & Homemaker - Cont. Home Care 701 3,914 15.00

16.00 Other 0 0 16.00

17.00 Drugs, Biological and Infusion Therapy 4,960 27,700 17.00

18.00 Analgesics 0 0 18.00

19.00 Sedatives / Hypnotics 0 0 19.00

20.00 Other - Specify 0 0 20.00

21.00 Durable Medical Equipment/Oxygen 58,987 329,416 21.00

22.00 Patient Transportation 0 0 22.00

23.00 Imaging Services 0 0 23.00

24.00 Labs and Diagnostics 0 0 24.00

25.00 Medical Supplies 0 0 25.00

26.00 Outpatient Services (including E/R Dept.) 0 0 26.00

27.00 Radiation Therapy 0 0 27.00

28.00 Chemotherapy 0 0 28.00

29.00 Other 0 0 29.00

30.00 Bereavement Program Costs 25,201 140,737 30.00

31.00 Volunteer Program Costs 0 0 31.00

32.00 Fundraising 124 692 32.00

33.00 Other Program Costs 0 0 33.00

34.00 Total (sum of lines 1 thru 33) (2) 2,838,154 34.00



MCRIF32 - 8.8.159.0 208 | Page


Date/Time Prepared:

Worksheet K-5

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537


STATISTICAL BASIS

Hospice I



(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #2

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #3

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #4

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #5

(SQUARE FEET)

1.00 1.01 1.02 1.03 1.04





5.00 Nursing Care 0 0 0 0 0 5.00











16.00 Other 0 0 0 0 0 16.00


18.00 Analgesics 0 0 0 0 0 18.00


20.00 Other - Specify 0 0 0 0 0 20.00








28.00 Chemotherapy 0 0 0 0 0 28.00

29.00 Other 0 0 0 0 0 29.00



32.00 Fundraising 0 0 0 0 0 32.00


34.00 Total (sum of lines 1 thru 33) (2) 0 0 0 0 0 34.00


36.00 Unit Cost Multiplier (see instructions) 0.000000 0.000000 0.000000 0.000000 0.000000 36.00


MCRIF32 - 8.8.159.0 209 | Page


Date/Time Prepared:

Worksheet K-5

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537


STATISTICAL BASIS

Hospice I



CSTS-BLDGS &

FIX #6

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #7

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #8

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #9

(SQUARE FEET)

NEW CAP-REL

CSTS-BLDGS &

FIX #1

(SQUARE FEE

T)

1.05 1.06 1.07 1.08 1.09

1.00 Administrative and General 0 0 0 3,286 0 1.00




5.00 Nursing Care 0 0 0 0 0 5.00











16.00 Other 0 0 0 0 0 16.00


18.00 Analgesics 0 0 0 0 0 18.00


20.00 Other - Specify 0 0 0 0 0 20.00








28.00 Chemotherapy 0 0 0 0 0 28.00

29.00 Other 0 0 0 0 0 29.00



32.00 Fundraising 0 0 0 0 0 32.00


34.00 Total (sum of lines 1 thru 33) (2) 0 0 0 3,286 0 34.00

35.00 Total cost to be allocated 0 0 0 57,051 0 35.00



MCRIF32 - 8.8.159.0 210 | Page


Date/Time Prepared:

Worksheet K-5

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537


STATISTICAL BASIS

Hospice I



CSTS-BLDGS &

FIX #1

(SQUARE FEE

T)

MVBLE EQUIP

(DIRECT COS

TS)

EMPLOYEE

BENEFITS

DEPARTMENT

(GROSS

SALARIES)

COMMUNICATION

S

(NONPATIENT)

Reconciliatio

n

1.10 2.00 4.00 5.01 5A.02

1.00 Administrative and General 0 324 203,410 37 0 1.00



4.00 Physician Services 0 0 201,178 0 0 4.00

5.00 Nursing Care 0 0 551,613 0 0 5.00






11.00 Spiritual Counseling 0 0 69,898 0 0 11.00




15.00 HH Aide & Homemaker - Cont. Home Care 0 0 35,084 0 0 15.00

16.00 Other 0 0 0 0 0 16.00


18.00 Analgesics 0 0 0 0 0 18.00


20.00 Other - Specify 0 0 0 0 0 20.00








28.00 Chemotherapy 0 0 0 0 0 28.00

29.00 Other 0 0 0 0 0 29.00

30.00 Bereavement Program Costs 0 0 28,378 0 0 30.00


32.00 Fundraising 0 0 6,203 0 0 32.00


34.00 Total (sum of lines 1 thru 33) (2) 0 324 1,177,509 37 34.00

35.00 Total cost to be allocated 0 321 88,265 9,134 35.00

36.00 Unit Cost Multiplier (see instructions) 0.000000 0.990741 0.074959 246.864865 36.00


MCRIF32 - 8.8.159.0 211 | Page


Date/Time Prepared:

Worksheet K-5

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537


STATISTICAL BASIS

Hospice I


PROCESSING

(ACCUM. COST)

PURCHASING

RECEIVING AND

STORES

(SUPPLY COS

TS)

ADMITTING

(GROSS REVE

NUES)

CASHIERING/AC

COUNTS

RECEIVABLE

(GROSS REVE

NUES)

Reconciliatio

n

5.02 5.03 5.04 5.05 5A.06

1.00 Administrative and General 81,753 10,258 2,759,839 2,759,839 0 1.00




5.00 Nursing Care 894,952 0 0 0 0 5.00











16.00 Other 0 0 0 0 0 16.00


18.00 Analgesics 0 0 0 0 0 18.00


20.00 Other - Specify 0 0 0 0 0 20.00








28.00 Chemotherapy 0 0 0 0 0 28.00

29.00 Other 0 0 0 0 0 29.00



32.00 Fundraising 465 0 0 0 0 32.00


34.00 Total (sum of lines 1 thru 33) (2) 1,968,682 10,258 2,759,839 2,759,839 34.00

35.00 Total cost to be allocated 113,827 2,479 9,933 14,867 35.00

36.00 Unit Cost Multiplier (see instructions) 0.057819 0.241665 0.003599 0.005387 36.00


MCRIF32 - 8.8.159.0 212 | Page


Date/Time Prepared:

Worksheet K-5

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537


STATISTICAL BASIS

Hospice I


ADMINISTRATIV

E & GENERAL

(ACCUM. COST)

MAINTENANCE &

REPAIRS

(REQUISITIO)

OPERATION OF

PLANT

(SQUARE FEET)

LAUNDRY &

LINEN SERVICE

(POUNDS OF

LAUNDRY)

HOUSEKEEPING

(SQUARE FEET)

5.06 6.00 7.00 8.00 9.00

1.00 Administrative and General 113,759 61 3,286 0 3,286 1.00




5.00 Nursing Care 946,697 0 0 0 0 5.00











16.00 Other 0 0 0 0 0 16.00


18.00 Analgesics 0 0 0 0 0 18.00


20.00 Other - Specify 0 0 0 0 0 20.00








28.00 Chemotherapy 0 0 0 0 0 28.00

29.00 Other 0 0 0 0 0 29.00



32.00 Fundraising 492 0 0 0 0 32.00


34.00 Total (sum of lines 1 thru 33) (2) 2,109,788 61 3,286 0 3,286 34.00

35.00 Total cost to be allocated 326,515 27,064 45,625 0 27,121 35.00



MCRIF32 - 8.8.159.0 213 | Page


Date/Time Prepared:

Worksheet K-5

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537


STATISTICAL BASIS

Hospice I


(MEALS

SERVED)

CAFETERIA

(MEALS

SERVED)

MAINTENANCE

OF PERSONNEL

(NUMBER

HOUSED)

NURSING

ADMINISTRATIO

N

(FTES SERV

ICE)

CENTRAL

SERVICES &

SUPPLY

(SUPPLY COS

TS)

10.00 11.00 12.00 13.00 14.00

1.00 Administrative and General 0 0 0 19 14,787 1.00




5.00 Nursing Care 0 0 0 0 0 5.00











16.00 Other 0 0 0 0 0 16.00


18.00 Analgesics 0 0 0 0 0 18.00


20.00 Other - Specify 0 0 0 0 0 20.00








28.00 Chemotherapy 0 0 0 0 0 28.00

29.00 Other 0 0 0 0 0 29.00



32.00 Fundraising 0 0 0 0 0 32.00


34.00 Total (sum of lines 1 thru 33) (2) 0 0 0 19 14,787 34.00

35.00 Total cost to be allocated 0 0 0 275,971 1,071 35.00

36.00 Unit Cost Multiplier (see instructions) 0.000000 0.000000 0.000000 14,524.789474 0.072428 36.00


MCRIF32 - 8.8.159.0 214 | Page


Date/Time Prepared:

Worksheet K-5

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537


STATISTICAL BASIS

Hospice I


(COSTED

REQUIS.)

MEDICAL

RECORDS &

LIBRARY

(TIME SPENT)

SOCIAL

SERVICE

(TIME SPENT)

NONPHYSICIAN

ANESTHETISTS

(ASSIGNED

TIME)

NURSING

SCHOOL

(ASSIGNED

TIME)

15.00 16.00 17.00 19.00 20.00





5.00 Nursing Care 0 0 0 0 528 5.00











16.00 Other 0 0 0 0 0 16.00


18.00 Analgesics 0 0 0 0 0 18.00


20.00 Other - Specify 0 0 0 0 0 20.00








28.00 Chemotherapy 0 0 0 0 0 28.00

29.00 Other 0 0 0 0 0 29.00



32.00 Fundraising 0 0 0 0 0 32.00



35.00 Total cost to be allocated 0 0 0 0 24,999 35.00



MCRIF32 - 8.8.159.0 215 | Page


Date/Time Prepared:

Worksheet K-5

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537


STATISTICAL BASIS

Hospice I

INTERNS & RESIDENTS


MEDICAL

TECHNOLOGY

(TIME SPENT)

SCHOOL OF

SURGICAL

TECHNOLOGY

(TIME SPENT)

SCHOOL OF

RADIOLOGICAL

TECHNOLO

(TIME SPENT)

SERVICES-SALA

RY & FRINGES

APPRV

(ASSIGNED

TIME)

SERVICES-OTHE

R PRGM COSTS

APPRV

(ASSIGNED

TIME)

20.01 20.02 20.03 21.00 22.00





5.00 Nursing Care 0 0 0 0 0 5.00











16.00 Other 0 0 0 0 0 16.00


18.00 Analgesics 0 0 0 0 0 18.00


20.00 Other - Specify 0 0 0 0 0 20.00








28.00 Chemotherapy 0 0 0 0 0 28.00

29.00 Other 0 0 0 0 0 29.00



32.00 Fundraising 0 0 0 0 0 32.00






MCRIF32 - 8.8.159.0 216 | Page


Date/Time Prepared:

Worksheet K-5

Part II

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537


STATISTICAL BASIS

Hospice I


EDUCATION

PROGRAM

(ASSIGNED

TIME)

23.00

1.00 Administrative and General 0 1.00

2.00 Inpatient - General Care 0 2.00

3.00 Inpatient - Respite Care 0 3.00

4.00 Physician Services 0 4.00

5.00 Nursing Care 0 5.00

6.00 Nursing Care-Continuous Home Care 0 6.00

7.00 Physical Therapy 0 7.00

8.00 Occupational Therapy 0 8.00

9.00 Speech/ Language Pathology 0 9.00

10.00 Medical Social Services 0 10.00

11.00 Spiritual Counseling 0 11.00

12.00 Dietary Counseling 0 12.00

13.00 Counseling - Other 0 13.00

14.00 Home Health Aide and Homemaker 0 14.00

15.00 HH Aide & Homemaker - Cont. Home Care 0 15.00

16.00 Other 0 16.00

17.00 Drugs, Biological and Infusion Therapy 0 17.00

18.00 Analgesics 0 18.00

19.00 Sedatives / Hypnotics 0 19.00

20.00 Other - Specify 0 20.00

21.00 Durable Medical Equipment/Oxygen 0 21.00

22.00 Patient Transportation 0 22.00

23.00 Imaging Services 0 23.00

24.00 Labs and Diagnostics 0 24.00

25.00 Medical Supplies 0 25.00

26.00 Outpatient Services (including E/R Dept.) 0 26.00

27.00 Radiation Therapy 0 27.00

28.00 Chemotherapy 0 28.00

29.00 Other 0 29.00

30.00 Bereavement Program Costs 0 30.00

31.00 Volunteer Program Costs 0 31.00

32.00 Fundraising 0 32.00

33.00 Other Program Costs 0 33.00

34.00 Total (sum of lines 1 thru 33) (2) 0 34.00

35.00 Total cost to be allocated 0 35.00



MCRIF32 - 8.8.159.0 217 | Page


Date/Time Prepared:

Worksheet K-5

Part III

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537

COMPUTATION OF TOTAL HOSPICE SHARED COSTS

Hospice I

Cost Center Description Wkst. C, Part

I, col. 11

line

Cost to

Charge Ratio

Total Hospice

Charges

(Provider

Records)

Hospice

Shared

Ancillary

Costs (cols.

1 x 2)

0 1.00 2.00 3.00


1.00 PHYSICAL THERAPY 1.0066.00 0.241650 0 0

1.01 SOUTHEAST OUTPATIENT REHAB 1.0166.01 0.305163 0 0

1.02 PHYSIATRY 1.0266.02 0.000000 0 0

2.00 OCCUPATIONAL THERAPY 2.0067.00 0.182238 0 0

3.00 SPEECH PATHOLOGY 3.0068.00 0.157783 0 0

4.00 DRUGS CHARGED TO PATIENTS 4.0073.00 0.215459 0 0

5.00 DURABLE MEDICAL EQUIP-RENTED 5.0096.00

6.00 LABORATORY 6.0060.00 0.177083 0 0

6.01 BLOOD LABORATORY 6.0160.01

7.00 MEDICAL SUPPLIES CHARGED TO PATIENT 7.0071.00 0.164812 0 0

8.00 OTHER OUTPATIENT SERVICE COST CENTER 8.0093.00

9.00 RADIOLOGY-THERAPEUTIC 9.0055.00 0.398830 0 0

9.01 CHEMOTHERAPY 9.0155.01 0.516072 0 0

10.00 CARDIAC REHAB 10.0076.00 0.000000 0 0

10.97 CARDIAC REHABILITATION 10.9776.97 0.892544 0 0

10.98 HYPERBARIC OXYGEN THERAPY 10.9876.98 0.000000 0 0

10.99 LITHOTRIPSY 10.9976.99 0.000000 0 0

11.00 Totals (sum of lines 1-10) 11.000


MCRIF32 - 8.8.159.0 218 | Page


Date/Time Prepared:

Worksheet K-6

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110

Hospice CCN: 261537

CALCULATION OF HOSPICE PER DIEM COST

Hospice I

Title XVIII Title XIX Other Total

1.00 2.00 3.00 4.00

1.00 Total cost (see instructions) 1.002,838,154

2.00 Total Unduplicated Days (Worksheet S-9, column 6, line 5) 2.0013,297

3.00 Average cost per diem (line 1 divided by line 2) 3.00213.44

4.00 Upduplicated Medicare Days (Worksheet S-9, column 1, line

5)

4.0012,549

5.00 Aggregate Medicare cost (line 3 time line 4) 5.002,678,459

6.00 Unduplicated Medicaid Days (Worksheet S-9, column 2, line

5)

6.00188

7.00 Aggregate Medicaid cost (line 3 time line 60) 7.0040,127

8.00 Upduplicated SNF Days (Worksheet S-9, column 3, line 5) 8.008,529

9.00 Aggregate SNF cost (line 3 time line 8) 9.001,820,430

10.00 Unduplicated NF Days (Worksheet S-9, column 4, line 5) 10.0013

11.00 Aggregate NF cost (line 3 times line 10) 11.002,775

12.00 Other Unduplicated days (Worksheet S-9, column 5, line 5) 12.00560

13.00 Aggregate cost for other days (line 3 times line 12) 13.00119,526


MCRIF32 - 8.8.159.0 219 | Page


Date/Time Prepared:

Worksheet L

Parts I-III

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110CALCULATION OF CAPITAL PAYMENT


1.00

PART I - FULLY PROSPECTIVE METHOD

CAPITAL FEDERAL AMOUNT

1.00 Capital DRG other than outlier 2,932,432 1.00

1.01 Model 4 BPCI Capital DRG other than outlier 0 1.01

2.00 Capital DRG outlier payments 425,061 2.00

2.01 Model 4 BPCI Capital DRG outlier payments 0 2.01

3.00 Total inpatient days divided by number of days in the cost reporting period (see instructions) 91.96 3.00

4.00 Number of interns & residents (see instructions) 0.00 4.00

5.00 Indirect medical education percentage (see instructions) 0.00 5.00

6.00 Indirect medical education adjustment (multiply line 5 by the sum of lines 1 and 1.01, columns 1 and

1.01)(see instructions)

0 6.00

7.00 Percentage of SSI recipient patient days to Medicare Part A patient days (Worksheet E, part A line


7.27 7.00

8.00 Percentage of Medicaid patient days to total days (see instructions) 17.14 8.00

9.00 Sum of lines 7 and 8 24.41 9.00

10.00 Allowable disproportionate share percentage (see instructions) 5.06 10.00

11.00 Disproportionate share adjustment (see instructions) 148,381 11.00

12.00 Total prospective capital payments (see instructions) 3,505,874 12.00

1.00

PART II - PAYMENT UNDER REASONABLE COST

1.00 Program inpatient routine capital cost (see instructions) 0 1.00

2.00 Program inpatient ancillary capital cost (see instructions) 0 2.00

3.00 Total inpatient program capital cost (line 1 plus line 2) 0 3.00

4.00 Capital cost payment factor (see instructions) 0 4.00

5.00 Total inpatient program capital cost (line 3 x line 4) 0 5.00

1.00

PART III - COMPUTATION OF EXCEPTION PAYMENTS

1.00 Program inpatient capital costs (see instructions) 0 1.00

2.00 Program inpatient capital costs for extraordinary circumstances (see instructions) 0 2.00

3.00 Net program inpatient capital costs (line 1 minus line 2) 0 3.00

4.00 Applicable exception percentage (see instructions) 0.00 4.00

5.00 Capital cost for comparison to payments (line 3 x line 4) 0 5.00

6.00 Percentage adjustment for extraordinary circumstances (see instructions) 0.00 6.00

7.00 Adjustment to capital minimum payment level for extraordinary circumstances (line 2 x line 6) 0 7.00

8.00 Capital minimum payment level (line 5 plus line 7) 0 8.00

9.00 Current year capital payments (from Part I, line 12, as applicable) 0 9.00

10.00 Current year comparison of capital minimum payment level to capital payments (line 8 less line 9) 0 10.00

11.00 Carryover of accumulated capital minimum payment level over capital payment (from prior year

Worksheet L, Part III, line 14)

0 11.00

12.00 Net comparison of capital minimum payment level to capital payments (line 10 plus line 11) 0 12.00

13.00 Current year exception payment (if line 12 is positive, enter the amount on this line) 0 13.00

14.00 Carryover of accumulated capital minimum payment level over capital payment for the following period

(if line 12 is negative, enter the amount on this line)

0 14.00

15.00 Current year allowable operating and capital payment (see instructions) 0 15.00

16.00 Current year operating and capital costs (see instructions) 0 16.00

17.00 Current year exception offset amount (see instructions) 0 17.00


MCRIF32 - 8.8.159.0 220 | Page


Date/Time Prepared:

Worksheet M-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110


ANALYSIS OF HOSPITAL-BASED RURAL HEALTH CLINIC/FEDERALLY QUALIFIED

HEALTH CENTER COSTS

Rural Health

Clinic (RHC) II

Cost

Compensation Other Costs Total (col. 1

+ col. 2)

Reclassificat

ions

Reclassified

Trial Balance

(col. 3 +

col. 4)

1.00 2.00 3.00 4.00 5.00

FACILITY HEALTH CARE STAFF COSTS

1.00 Physician 1,276,391 47,941 1,324,332 0 1,324,332 1.00

2.00 Physician Assistant 253,673 0 253,673 0 253,673 2.00

3.00 Nurse Practitioner 0 0 0 0 0 3.00

4.00 Visiting Nurse 0 0 0 0 0 4.00

5.00 Other Nurse 370,396 0 370,396 0 370,396 5.00

6.00 Clinical Psychologist 0 0 0 0 0 6.00

7.00 Clinical Social Worker 0 0 0 0 0 7.00

8.00 Laboratory Technician 0 0 0 0 0 8.00

9.00 Other Facility Health Care Staff Costs 23,176 0 23,176 0 23,176 9.00

10.00 Subtotal (sum of lines 1 through 9) 1,923,636 47,941 1,971,577 0 1,971,577 10.00

11.00 Physician Services Under Agreement 0 0 0 0 0 11.00

12.00 Physician Supervision Under Agreement 0 0 0 0 0 12.00

13.00 Other Costs Under Agreement 0 0 0 0 0 13.00

14.00 Subtotal (sum of lines 11 through 13) 0 0 0 0 0 14.00

15.00 Medical Supplies 0 158,436 158,436 0 158,436 15.00

16.00 Transportation (Health Care Staff) 0 0 0 0 0 16.00

17.00 Depreciation-Medical Equipment 0 0 0 0 0 17.00

18.00 Professional Liability Insurance 0 51,143 51,143 0 51,143 18.00

19.00 Other Health Care Costs 0 0 0 0 0 19.00

20.00 Allowable GME Costs 0 0 0 0 0 20.00

21.00 Subtotal (sum of lines 15 through 20) 0 209,579 209,579 0 209,579 21.00

22.00 Total Cost of Health Care Services (sum of

lines 10, 14, and 21)

1,923,636 257,520 2,181,156 0 2,181,156 22.00

COSTS OTHER THAN RHC/FQHC SERVICS

23.00 Pharmacy 0 0 0 0 0 23.00

24.00 Dental 0 0 0 0 0 24.00

25.00 Optometry 0 0 0 0 0 25.00

26.00 All other nonreimbursable costs 0 0 0 0 0 26.00

27.00 Nonallowable GME costs 0 0 0 0 0 27.00

28.00 Total Nonreimbursable Costs (sum of lines 23

through 27)

0 0 0 0 0 28.00

FACILITY OVERHEAD

29.00 Facility Costs 0 0 0 0 0 29.00

30.00 Administrative Costs 201,764 238,914 440,678 0 440,678 30.00

31.00 Total Facility Overhead (sum of lines 29 and

30)

201,764 238,914 440,678 0 440,678 31.00

32.00 Total facility costs (sum of lines 22, 28

and 31)

2,125,400 496,434 2,621,834 0 2,621,834 32.00


MCRIF32 - 8.8.159.0 221 | Page


Date/Time Prepared:

Worksheet M-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110



HEALTH CENTER COSTS

Rural Health

Clinic (RHC) II

Cost


for

Allocation

(col. 5 +

col. 6)

6.00 7.00


1.00 Physician 0 1,324,332 1.00

2.00 Physician Assistant 0 253,673 2.00

3.00 Nurse Practitioner 0 0 3.00

4.00 Visiting Nurse 0 0 4.00

5.00 Other Nurse 0 370,396 5.00

6.00 Clinical Psychologist 0 0 6.00

7.00 Clinical Social Worker 0 0 7.00

8.00 Laboratory Technician 0 0 8.00

9.00 Other Facility Health Care Staff Costs 0 23,176 9.00

10.00 Subtotal (sum of lines 1 through 9) 0 1,971,577 10.00

11.00 Physician Services Under Agreement 0 0 11.00

12.00 Physician Supervision Under Agreement 0 0 12.00

13.00 Other Costs Under Agreement 0 0 13.00


15.00 Medical Supplies 0 158,436 15.00

16.00 Transportation (Health Care Staff) 0 0 16.00

17.00 Depreciation-Medical Equipment 0 0 17.00

18.00 Professional Liability Insurance 0 51,143 18.00

19.00 Other Health Care Costs 0 0 19.00

20.00 Allowable GME Costs 0 0 20.00

21.00 Subtotal (sum of lines 15 through 20) 0 209,579 21.00


lines 10, 14, and 21)

0 2,181,156 22.00


23.00 Pharmacy 0 0 23.00

24.00 Dental 0 0 24.00

25.00 Optometry 0 0 25.00

26.00 All other nonreimbursable costs 0 0 26.00

27.00 Nonallowable GME costs 0 0 27.00


through 27)

0 0 28.00

FACILITY OVERHEAD

29.00 Facility Costs 0 0 29.00

30.00 Administrative Costs -8,176 432,502 30.00


30)

-8,176 432,502 31.00


and 31)

-8,176 2,613,658 32.00


MCRIF32 - 8.8.159.0 222 | Page


Date/Time Prepared:

Worksheet M-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110



HEALTH CENTER COSTS

Rural Health

Clinic (RHC) III

Cost

Compensation Other Costs Total (col. 1

+ col. 2)

Reclassificat

ions

Reclassified

Trial Balance

(col. 3 +

col. 4)

1.00 2.00 3.00 4.00 5.00


1.00 Physician 1,105,701 23,707 1,129,408 0 1,129,408 1.00

2.00 Physician Assistant 80,375 0 80,375 0 80,375 2.00

3.00 Nurse Practitioner 0 0 0 0 0 3.00

4.00 Visiting Nurse 0 0 0 0 0 4.00

5.00 Other Nurse 222,335 0 222,335 0 222,335 5.00

6.00 Clinical Psychologist 0 0 0 0 0 6.00

7.00 Clinical Social Worker 0 0 0 0 0 7.00

8.00 Laboratory Technician 0 0 0 0 0 8.00

9.00 Other Facility Health Care Staff Costs 0 0 0 0 0 9.00

10.00 Subtotal (sum of lines 1 through 9) 1,408,411 23,707 1,432,118 0 1,432,118 10.00

11.00 Physician Services Under Agreement 0 0 0 0 0 11.00

12.00 Physician Supervision Under Agreement 0 0 0 0 0 12.00

13.00 Other Costs Under Agreement 0 0 0 0 0 13.00

14.00 Subtotal (sum of lines 11 through 13) 0 0 0 0 0 14.00

15.00 Medical Supplies 0 511,670 511,670 0 511,670 15.00

16.00 Transportation (Health Care Staff) 0 0 0 0 0 16.00

17.00 Depreciation-Medical Equipment 0 0 0 0 0 17.00

18.00 Professional Liability Insurance 0 26,155 26,155 0 26,155 18.00

19.00 Other Health Care Costs 0 0 0 0 0 19.00

20.00 Allowable GME Costs 0 0 0 0 0 20.00

21.00 Subtotal (sum of lines 15 through 20) 0 537,825 537,825 0 537,825 21.00


lines 10, 14, and 21)

1,408,411 561,532 1,969,943 0 1,969,943 22.00


23.00 Pharmacy 0 0 0 0 0 23.00

24.00 Dental 0 0 0 0 0 24.00

25.00 Optometry 0 0 0 0 0 25.00

26.00 All other nonreimbursable costs 0 0 0 0 0 26.00

27.00 Nonallowable GME costs 0 0 0 0 0 27.00


through 27)

0 0 0 0 0 28.00

FACILITY OVERHEAD

29.00 Facility Costs 0 0 0 0 0 29.00

30.00 Administrative Costs 121,593 151,124 272,717 0 272,717 30.00


30)

121,593 151,124 272,717 0 272,717 31.00


and 31)

1,530,004 712,656 2,242,660 0 2,242,660 32.00


MCRIF32 - 8.8.159.0 223 | Page


Date/Time Prepared:

Worksheet M-1

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110



HEALTH CENTER COSTS

Rural Health

Clinic (RHC) III

Cost


for

Allocation

(col. 5 +

col. 6)

6.00 7.00


1.00 Physician 0 1,129,408 1.00

2.00 Physician Assistant 0 80,375 2.00

3.00 Nurse Practitioner 0 0 3.00

4.00 Visiting Nurse 0 0 4.00

5.00 Other Nurse 0 222,335 5.00

6.00 Clinical Psychologist 0 0 6.00

7.00 Clinical Social Worker 0 0 7.00

8.00 Laboratory Technician 0 0 8.00

9.00 Other Facility Health Care Staff Costs 0 0 9.00

10.00 Subtotal (sum of lines 1 through 9) 0 1,432,118 10.00

11.00 Physician Services Under Agreement 0 0 11.00

12.00 Physician Supervision Under Agreement 0 0 12.00

13.00 Other Costs Under Agreement 0 0 13.00


15.00 Medical Supplies 0 511,670 15.00

16.00 Transportation (Health Care Staff) 0 0 16.00

17.00 Depreciation-Medical Equipment 0 0 17.00

18.00 Professional Liability Insurance 0 26,155 18.00

19.00 Other Health Care Costs 0 0 19.00

20.00 Allowable GME Costs 0 0 20.00

21.00 Subtotal (sum of lines 15 through 20) 0 537,825 21.00


lines 10, 14, and 21)

0 1,969,943 22.00


23.00 Pharmacy 0 0 23.00

24.00 Dental 0 0 24.00

25.00 Optometry 0 0 25.00

26.00 All other nonreimbursable costs 0 0 26.00

27.00 Nonallowable GME costs 0 0 27.00


through 27)

0 0 28.00

FACILITY OVERHEAD

29.00 Facility Costs 0 0 29.00

30.00 Administrative Costs -5,524 267,193 30.00


30)

-5,524 267,193 31.00


and 31)

-5,524 2,237,136 32.00


MCRIF32 - 8.8.159.0 224 | Page


Date/Time Prepared:

Worksheet M-2

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110


ALLOCATION OF OVERHEAD TO RHC/FQHC SERVICES

Rural Health

Clinic (RHC) II

Cost

Number of FTE

Personnel

Total Visits Productivity

Standard (1)

Minimum

Visits (col.

1 x col. 3)

Greater of

col. 2 or

col. 4

1.00 2.00 3.00 4.00 5.00

VISITS AND PRODUCTIVITY

Positions

1.00 Physician 4.28 19,532 4,200 17,976 1.00

2.00 Physician Assistant 0.00 0 2,100 0 2.00

3.00 Nurse Practitioner 2.80 6,099 2,100 5,880 3.00

4.00 Subtotal (sum of lines 1 through 3) 7.08 25,631 23,856 25,631 4.00

5.00 Visiting Nurse 0.00 0 0 5.00

6.00 Clinical Psychologist 0.00 0 0 6.00

7.00 Clinical Social Worker 0.00 0 0 7.00

7.01 Medical Nutrition Therapist (FQHC only) 0.00 0 0 7.01

7.02 Diabetes Self Management Training (FQHC

only)

0.00 0 0 7.02

8.00 Total FTEs and Visits (sum of lines 4

through 7)

7.08 25,631 25,631 8.00

9.00 Physician Services Under Agreements 0 0 9.00

1.00

DETERMINATION OF ALLOWABLE COST APPLICABLE TO RHC/FQHC SERVICES

10.00 Total costs of health care services (from Wkst. M-1, col. 7, line 22) 2,181,156 10.00

11.00 Total nonreimbursable costs (from Wkst. M-1, col. 7, line 28) 0 11.00

12.00 Cost of all services (excluding overhead) (sum of lines 10 and 11) 2,181,156 12.00

13.00 Ratio of RHC/FQHC services (line 10 divided by line 12) 1.000000 13.00

14.00 Total facility overhead - (from Wkst. M-1, col. 7, line 31) 432,502 14.00

15.00 Parent provider overhead allocated to facility (see instructions) 1,682,555 15.00

16.00 Total overhead (sum of lines 14 and 15) 2,115,057 16.00

17.00 Allowable GME overhead (see instructions) 0 17.00


19.00 Overhead applicable to RHC/FQHC services (line 13 x line 18) 2,115,057 19.00

20.00 Total allowable cost of RHC/FQHC services (sum of lines 10 and 19) 4,296,213 20.00


MCRIF32 - 8.8.159.0 225 | Page


Date/Time Prepared:

Worksheet M-2

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110


ALLOCATION OF OVERHEAD TO RHC/FQHC SERVICES

Rural Health

Clinic (RHC) III

Cost

Number of FTE

Personnel

Total Visits Productivity

Standard (1)

Minimum

Visits (col.

1 x col. 3)

Greater of

col. 2 or

col. 4

1.00 2.00 3.00 4.00 5.00

VISITS AND PRODUCTIVITY

Positions

1.00 Physician 3.55 17,007 4,200 14,910 1.00

2.00 Physician Assistant 0.00 0 2,100 0 2.00

3.00 Nurse Practitioner 0.81 2,340 2,100 1,701 3.00

4.00 Subtotal (sum of lines 1 through 3) 4.36 19,347 16,611 19,347 4.00

5.00 Visiting Nurse 0.00 0 0 5.00

6.00 Clinical Psychologist 0.00 0 0 6.00

7.00 Clinical Social Worker 0.00 0 0 7.00

7.01 Medical Nutrition Therapist (FQHC only) 0.00 0 0 7.01

7.02 Diabetes Self Management Training (FQHC

only)

0.00 0 0 7.02

8.00 Total FTEs and Visits (sum of lines 4

through 7)

4.36 19,347 19,347 8.00

9.00 Physician Services Under Agreements 0 0 9.00

1.00

DETERMINATION OF ALLOWABLE COST APPLICABLE TO RHC/FQHC SERVICES

10.00 Total costs of health care services (from Wkst. M-1, col. 7, line 22) 1,969,943 10.00

11.00 Total nonreimbursable costs (from Wkst. M-1, col. 7, line 28) 0 11.00

12.00 Cost of all services (excluding overhead) (sum of lines 10 and 11) 1,969,943 12.00

13.00 Ratio of RHC/FQHC services (line 10 divided by line 12) 1.000000 13.00

14.00 Total facility overhead - (from Wkst. M-1, col. 7, line 31) 267,193 14.00

15.00 Parent provider overhead allocated to facility (see instructions) 1,256,778 15.00

16.00 Total overhead (sum of lines 14 and 15) 1,523,971 16.00

17.00 Allowable GME overhead (see instructions) 0 17.00


19.00 Overhead applicable to RHC/FQHC services (line 13 x line 18) 1,523,971 19.00

20.00 Total allowable cost of RHC/FQHC services (sum of lines 10 and 19) 3,493,914 20.00


MCRIF32 - 8.8.159.0 226 | Page


Date/Time Prepared:

Worksheet M-3

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110


CALCULATION OF REIMBURSEMENT SETTLEMENT FOR RHC/FQHC SERVICES

Title XVIII Rural Health

Clinic (RHC) II

Cost

1.00

DETERMINATION OF RATE FOR RHC/FQHC SERVICES

1.00 Total Allowable Cost of RHC/FQHC Services (from Wkst. M-2, line 20) 4,296,213 1.00

2.00 Cost of vaccines and their administration (from Wkst. M-4, line 15) 118,210 2.00

3.00 Total allowable cost excluding vaccine (line 1 minus line 2) 4,178,003 3.00

4.00 Total Visits (from Wkst. M-2, column 5, line 8) 25,631 4.00

5.00 Physicians visits under agreement (from Wkst. M-2, column 5, line 9) 0 5.00

6.00 Total adjusted visits (line 4 plus line 5) 25,631 6.00

7.00 Adjusted cost per visit (line 3 divided by line 6) 163.01 7.00

Calculation of Limit (1)

Prior to

January 1

On on After

January 1

1.00 2.00

8.00 Per visit payment limit (from CMS Pub. 100-04, chapter 9, §20.6 or your contractor) 0.00 80.44 8.00

9.00 Rate for Program covered visits (see instructions) 0.00 80.44 9.00

CALCULATION OF SETTLEMENT

10.00 Program covered visits excluding mental health services (from contractor records) 0 7,087 10.00

11.00 Program cost excluding costs for mental health services (line 9 x line 10) 0 570,078 11.00

12.00 Program covered visits for mental health services (from contractor records) 0 0 12.00

13.00 Program covered cost from mental health services (line 9 x line 12) 0 0 13.00

14.00 Limit adjustment for mental health services (see instructions) 0 0 14.00

15.00 Graduate Medical Education Pass Through Cost (see instructions) 0 15.00

16.00 Total Program cost (sum of lines 11, 14, and 15, columns 1, 2 and 3) * 570,078 16.00

16.01 Total program charges (see instructions)(from contractor's records) 909,653 16.01

16.02 Total program preventive charges (see instructions)(from provider's records) 43,817 16.02

16.03 Total program preventive costs ((line 16.02/line 16.01) times line 16) 27,460 16.03

16.04 Total Program non-preventive costs ((line 16 minus lines 16.03 and 18) times .80)

(Titles V and XIX see instructions.)

360,637 16.04

16.05 Total program cost (see instructions) 388,097 16.05

17.00 Primary payer amounts 1,534 17.00

18.00 Less: Beneficiary deductible for RHC only (see instructions) (from contractor

records)

91,822 18.00

19.00 Beneficiary coinsurance for RHC/FQHC services (see instructions) (from contractor

records)

154,803 19.00

20.00 Net Medicare cost excluding vaccines (see instructions) 386,563 20.00

21.00 Program cost of vaccines and their administration (from Wkst. M-4, line 16) 13,279 21.00

22.00 Total reimbursable Program cost (line 20 plus line 21) 399,842 22.00






26.00 Net reimbursable amount (see instructions) 399,906 26.00


27.00 Interim payments 372,798 27.00


29.00 Balance due component/program (line 26 minus lines 26.01, 27, and 28) 19,110 29.00

30.00 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-II,

chapter I, §115.2

0 30.00


MCRIF32 - 8.8.159.0 227 | Page


Date/Time Prepared:

Worksheet M-3

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110


CALCULATION OF REIMBURSEMENT SETTLEMENT FOR RHC/FQHC SERVICES


Clinic (RHC) III

Cost

1.00

DETERMINATION OF RATE FOR RHC/FQHC SERVICES

1.00 Total Allowable Cost of RHC/FQHC Services (from Wkst. M-2, line 20) 3,493,914 1.00

2.00 Cost of vaccines and their administration (from Wkst. M-4, line 15) 0 2.00

3.00 Total allowable cost excluding vaccine (line 1 minus line 2) 3,493,914 3.00

4.00 Total Visits (from Wkst. M-2, column 5, line 8) 19,347 4.00

5.00 Physicians visits under agreement (from Wkst. M-2, column 5, line 9) 0 5.00

6.00 Total adjusted visits (line 4 plus line 5) 19,347 6.00

7.00 Adjusted cost per visit (line 3 divided by line 6) 180.59 7.00

Calculation of Limit (1)

Prior to

January 1

On on After

January 1

1.00 2.00

8.00 Per visit payment limit (from CMS Pub. 100-04, chapter 9, §20.6 or your contractor) 0.00 80.44 8.00

9.00 Rate for Program covered visits (see instructions) 0.00 80.44 9.00

CALCULATION OF SETTLEMENT

10.00 Program covered visits excluding mental health services (from contractor records) 0 0 10.00

11.00 Program cost excluding costs for mental health services (line 9 x line 10) 0 0 11.00

12.00 Program covered visits for mental health services (from contractor records) 0 0 12.00

13.00 Program covered cost from mental health services (line 9 x line 12) 0 0 13.00

14.00 Limit adjustment for mental health services (see instructions) 0 0 14.00

15.00 Graduate Medical Education Pass Through Cost (see instructions) 0 15.00

16.00 Total Program cost (sum of lines 11, 14, and 15, columns 1, 2 and 3) * 0 16.00

16.01 Total program charges (see instructions)(from contractor's records) 0 16.01

16.02 Total program preventive charges (see instructions)(from provider's records) 0 16.02

16.03 Total program preventive costs ((line 16.02/line 16.01) times line 16) 0 16.03

16.04 Total Program non-preventive costs ((line 16 minus lines 16.03 and 18) times .80)

(Titles V and XIX see instructions.)

0 16.04

16.05 Total program cost (see instructions) 0 16.05

17.00 Primary payer amounts 0 17.00

18.00 Less: Beneficiary deductible for RHC only (see instructions) (from contractor

records)

0 18.00

19.00 Beneficiary coinsurance for RHC/FQHC services (see instructions) (from contractor

records)

0 19.00

20.00 Net Medicare cost excluding vaccines (see instructions) 0 20.00

21.00 Program cost of vaccines and their administration (from Wkst. M-4, line 16) 0 21.00

22.00 Total reimbursable Program cost (line 20 plus line 21) 0 22.00






26.00 Net reimbursable amount (see instructions) 0 26.00




29.00 Balance due component/program (line 26 minus lines 26.01, 27, and 28) 0 29.00

30.00 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-II,

chapter I, §115.2

0 30.00


MCRIF32 - 8.8.159.0 228 | Page


Date/Time Prepared:

Worksheet M-4

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110


COMPUTATION OF PNEUMOCOCCAL AND INFLUENZA VACCINE COST


Clinic (RHC) II

Cost

Pneumococcal Influenza

1.00 2.00

1.00 Health care staff cost (from Wkst. M-1, col. 7, line 10) 1,971,577 1,971,577 1.00

2.00 Ratio of pneumococcal and influenza vaccine staff time to total health care staff time 0.001570 0.003792 2.00

3.00 Pneumococcal and influenza vaccine health care staff cost (line 1 x line 2) 3,095 7,476 3.00

4.00 Medical supplies cost - pneumococcal and influenza vaccine (from your records) 36,563 12,880 4.00

5.00 Direct cost of pneumococcal and influenza vaccine (line 3 plus line 4) 39,658 20,356 5.00

6.00 Total direct cost of the facility (from Wkst. M-1, col. 7, line 22) 2,181,156 2,181,156 6.00

7.00 Total overhead (from Wkst. M-2, line 16) 2,115,057 2,115,057 7.00

8.00 Ratio of pneumococcal and influenza vaccine direct cost to total direct cost (line 5

divided by line 6)

0.018182 0.009333 8.00

9.00 Overhead cost - pneumococcal and influenza vaccine (line 7 x line 8) 38,456 19,740 9.00

10.00 Total pneumococcal and influenza vaccine cost and its (their) administration (sum of

lines 5 and 9)

78,114 40,096 10.00

11.00 Total number of pneumococcal and influenza vaccine injections (from your records) 332 802 11.00

12.00 Cost per pneumococcal and influenza vaccine injection (line 10/line 11) 235.28 50.00 12.00

13.00 Number of pneumococcal and influenza vaccine injections administered to Program

beneficiaries

32 115 13.00

14.00 Program cost of pneumococcal and influenza vaccine and its (their) administration

(line 12 x line 13)

7,529 5,750 14.00

15.00 Total cost of pneumococcal and influenza vaccine and its (their) administration (sum

of cols. 1 and 2, line 10) (transfer this amount to Wkst. M-3, line 2)

118,210 15.00

16.00 Total Program cost of pneumococcal and influenza vaccine and its (their)

administration (sum of cols. 1 and 2, line 14) (transfer this amount to Wkst. M-3,

line 21)

13,279 16.00


MCRIF32 - 8.8.159.0 229 | Page


Date/Time Prepared:

Worksheet M-5

5/25/2016 12:02 pm

Period:

To

From 01/01/2015

12/31/2015

Provider CCN:260110


ANALYSIS OF PAYMENTS TO HOSPITAL-BASED RHC/FQHC PROVIDER FOR SERVICES

RENDERED TO PROGRAM BENEFICIARIES

Rural Health

Clinic (RHC) II

Cost

Part B

mm/dd/yyyy Amount

1.00 2.00

1.00 Total interim payments paid to provider 372,798 1.00

2.00 Interim payments payable on individual bills, either submitted or to be submitted to

the contractor for services rendered in the cost reporting period. If none, write

"NONE" or enter a zero

0 2.00

3.00 List separately each retroactive lump sum adjustment amount based on subsequent

revision of the interim rate for the cost reporting period. Also show date of each


3.00

Program to Provider

3.01 0 3.01

3.02 0 3.02

3.03 0 3.03

3.04 0 3.04

3.05 0 3.05

Provider to Program

3.50 0 3.50

3.51 0 3.51

3.52 0 3.52

3.53 0 3.53

3.54 0 3.54

3.99 Subtotal (sum of lines 3.01-3.49 minus sum of lines 3.50-3.98) 0 3.99

4.00 Total interim payments (sum of lines 1, 2, and 3.99) (transfer to Worksheet M-3, line

27)

372,798 4.00


5.00 List separately each tentative settlement payment after desk review. Also show date of

each payment. If none, write "NONE" or enter a zero. (1)

5.00

Program to Provider

5.01 0 5.01

5.02 0 5.02

5.03 0 5.03

Provider to Program

5.50 0 5.50

5.51 0 5.51

5.52 0 5.52

5.99 Subtotal (sum of lines 5.01-5.49 minus sum of lines 5.50-5.98) 0 5.99

6.00 Determined net settlement amount (balance due) based on the cost report. (1) 6.00

6.01 SETTLEMENT TO PROVIDER 19,110 6.01

6.02 SETTLEMENT TO PROGRAM 0 6.02

7.00 Total Medicare program liability (see instructions) 391,908 7.00

Contractor

Number

NPR Date

(Mo/Day/Yr)

0 1.00 2.00



MCRIF32 - 8.8.159.0 230 | Page

southeasthealth title xviii medicare cost report...title xviii title v part a part b hit title xix...

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