PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX COST REPORT WORKSHEET S CERTIFICATION AND SETTLEMENT SUMMARY PARTS I & II INTERMEDIARY [ ] AUDITED DATE RECEIVED ________ [ ] INITIAL [ ] RE-OPENING USE ONLY: [ XX ] DESK REVIEWED INTERMEDIARY NO. ________ [ ] FINAL [ XX ] MCR CODE 1 PART I - CERTIFICATION CHECK XX ELECTRONICALLY FILED COST REPORT DATE: 05/29/2009 APPLICABLE BOX __ MANUALLY SUBMITTED COST REPORT TIME: 10:07_____ 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 WHERE 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 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 HUNTINGTON MEMORIAL HOSPITAL (15-0091) (PROVIDER NAME(S) AND NUMBER(S)) FOR THE COST REPORTING PERIOD BEGINNING 01/01/2008 AND ENDING 12/31/2008, AND THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF, IT IS A TRUE, CORRECT AND COMPLETE STATEMENT 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 PART II - SETTLEMENT SUMMARY TITLE V TITLE XVIII TITLE XIX PART A PART B 1 2 3 4 1 HOSPITAL 24839 38445 1 2 SUBPROVIDER I 2 3 SWING BED - SNF 3 4 SWING BED - NF 4 5 SKILLED NURSING FACILITY 5 6 NURSING FACILITY 6 7 HOME HEALTH AGENCY 7 8 OUTPATIENT REHABILITATION PROVIDER 8 9 HEALTH CLINIC 9 100 TOTAL 24839 38445 100 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 OMD CONTROL NUMBER. THE VALID OMB CONTROL NUMBER FOR THIS INFORMATION COLLECTION IS 0938-0050. THE TIME REQUIRED TO COMPLETE THIS INFORMATION COLLECTION IS ESTIMATED 657 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 THIS FORM, PLEASE WRITE TO: HEALTH CARE FINANCING ADMINISTRATION, 7500 SECURITY BOULEVARD, N2-14-26, BALTIMORE, MARYLAND 21244-1850, AND TO THE OFFICE OF THE INFORMATION AND REGULATORY AFFAIRS, OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, D.C. 20503. PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (05/2007) 05/29/2009 10:07 HOSPITAL AND HEALTH CARE COMPLEX IDENTIFICATION DATA WORKSHEET S-2 HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX ADDRESS: 1 STREET: 2001 STULTS ROAD P.O.BOX: 1 1.01 CITY: HUNTINGTON STATE: IN ZIP CODE: 46750 COUNTY: HUNTINGTON 1.01 HOSPITAL AND HOSPITAL-BASED COMPONENT IDENTIFICATION: PAYMENT SYSTEM PROVIDER DATE (P,T,O OR N) COMPONENT COMPONENT NAME NUMBER CERTIFIED V XVIII XIX 0 1 2 3 4 5 6 2 HOSPITAL HUNTINGTON MEMORIAL HOSPITAL 15-0091 07/01/1966 N P P 2 3 SUBPROVIDER I 3 4 SWING BEDS - SNF 4 5 SWING BEDS - NF 5 6 HOSPITAL-BASED SNF 6 7 HOSPITAL-BASED NF 7 8 HOSPITAL-BASED OLTC 8 9 HOSPITAL-BASED HHA 9 11 SEPARATELY CERTIFIED ASC 11 12 HOSPITAL-BASED HOSPICE 12 14 HOSP-BASED RHC 14 15 OUTPATIENT REHABILITATION PROVID 15 16 RENAL DIALYSIS 16 17 COST REPORTING PERIOD (MM/DD/YYYY) FROM: 01/01/2008 TO: 12/31/2008 17 1 2 18 TYPE OF CONTROL 2 18 TYPE OF HOSPITAL/SUBPROVIDER 19 HOSPITAL 1 19 20 SUBPROVIDER I 20 OTHER INFORMATION 21 INDICATE IF YOUR HOSPITAL IS EITHER (1) URBAN OR (2) RURAL AT THE END OF THE 21 COST REPORTING PERIOD IN COLUMN 1. IF YOUR HOSPITAL IS GEOGRAPHICALLY CLASSIFIED OR LOCATED IN A RURAL AREA, IS YOUR BED SIZE IN ACCORDANCE WITH CFR 42 412.105 LESS THAN OR EQUAL TO 100 BEDS, ENTER IN COLUMN 2 'Y' FOR YES OR 'N' FOR NO. 21.01 DOES YOUR FACILITY QUALIFY AND IS CURRENTLY RECEIVING PAYMENT FOR YES 21.01 DISPROPORTIONATE SHARE IN ACCORDANCE WITH 42 CFR 412.106? 21.02 HAS YOUR FACILITY RECEIVED GEOGRAPHIC RECLASSIFICATION? ENTER 'Y' FOR YES 21.02 AND 'N' FOR NO. IF YES, REPORT IN COLUMN 2 THE EFFECTIVE DATE. 21.03 ENTER IN COLUMN 1 YOUR GEOGRAPHIC LOCATION EITHER (1) URBAN (2) RURAL. IF YOU ANSWERED 1 N Y 21.03 URBAN IN COLUMN 1 INDICATE IF YOU RECEIVED EITHER A WAGE OR STANDARD GEOGRAPHIC RECLASSIFICATION TO A RURAL LOCATION, ENTER IN COLUMN 2 'Y' AND 'N' FOR NO. IF COLUMN 2 IS YES, ENTER IN COLUMN 3 THE EFFECTIVE DATE (mm/dd/yyyy)(SEE INSTRUCTION). DOES YOUR FACILITY CONTAIN 100 OR FEWER BEDS IN ACCORDANCE WITH 42 CFR 412.105? ENTER IN COLUMN 4 'Y' FOR YES AND 'N' FOR NO. ENTER IN COLUMN 5 THE PROVIDERS ACTUAL MSA OR CBSA. 21.04 FOR STANDARD GEOGRAPHIC RECLASSIFICATION (NOT WAGE), WHAT IS YOUR STATUS AT THE BEGINNING 1 21.04 OF THE COST REPORTING PERIOD. ENTER (1) URBAN AND (2) RURAL. 21.05 FOR STANDARD GEOGRAPHIC RECLASSIFICATION (NOT WAGE), WHAT IS YOUR STATUS AT THE END OF THE 1 21.05 COST REPORTING PERIOD. ENTER (1) URBAN AND (2) RURAL. 21.06 DOES THIS HOSPITAL QUALIFY FOR THE THREE-YEAR TRANSITION OF HOLD HARMLESS PAYMENTS FOR A NO 21.06 SMALL RURAL HOSPITAL UNDER THE PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL OUTPATIENT SERVICES UNDER DRA SECTION 5105? ENTER 'Y' FOR YES AND 'N' FOR NO. 22 ARE YOU CLASSIFIED AS A REFERRAL CENTER? NO 22 23 DOES THIS FACILITY OPERATE A TRANSPLANT CENTER? IF YES, ENTER CERTIFICATION DATE(S) BELOW NO 23 23.01 IF THIS IS A MEDICARE CERTIFIED KIDNEY TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE 23.01 IN COL. 2 AND TERMINATION IN COl. 3. 23.02 IF THIS IS A MEDICARE CERTIFIED HEART TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE 23.02 IN COL. 2 AND TERMINATION IN COL. 3. 23.03 IF THIS IS A MEDICARE CERTIFIED LIVER TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE 23.03 IN COL. 2 AND TERMINATION IN COL. 3. 23.04 IF THIS IS A MEDICARE CERTIFIED LUNG TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE 23.04 IN COL. 2 AND TERMINATION IN COL. 3. 23.05 IF MEDICARE PANCREAS TRANSPLANTS ARE PERFORMED SEE INSTRUCTIONS FOR ENTERING CERTIFICATION 23.05 AND TERMINATION DATE. 23.06 IF THIS IS A MEDICARE CERTIFIED INTESTINAL TRANSPLANT CENTER, ENTER THE CERTIFICATION 23.06 DATE IN COL. 2 AND TERMINATION IN COL. 3. 23.07 IF THIS IS A MEDICARE CERTIFIED ISLET TRANSPLANT CENTER ENTER THE CERTIFICATION DATE 23.07 IN COL. 2 AND TERMINATION IN COL. 3. 24 IF THIS AN ORGAN PROCUREMENT ORGANIZATION (OPO), ENTER THE OPO NUMBER IN COL 2. 24 AND TERMINATION IN COL. 3. 24.01 IF THIS A MEDICARE TRANSPLANT CENTER; ENTER THE CCN (PROVIDER NUMBER) IN COL 2, THE 24.01 CERTIFICATION DATE OR RECERTIFICATION DATE (AFTER DECEMBER 26, 2007) IN COL 3. 25 IS THIS A TEACHING HOSPITAL OR AFFILIATED WITH A TEACHING HOSPITAL AND YOU ARE MAKING NO 25 PAYMENTS FOR I & R? 25.01 IS THIS TEACHING PROGRAM APPROVED IN ACCORDANCE WITH CMS PUB. 15-I, CHAPTER 4? NO 25.01 25.02 IF LINE 25.01 IS YES, WAS MEDICARE PARTICIPATION AND APPROVED TEACHING PROGRAM STATUS NO 25.02 IN EFFECT DURING THE FIRST MONTH OF THE COST REPORTING PERIOD? IF YES, COMPLETE WORKSHEET E-3, PART IV. IF NO, COMPLETE WORKSHEET D-2, PART II. 25.03 AS A TEACHING HOSPITAL, DID YOU ELECT COST REIMBURSEMENT FOR PHYSICIANS' SERVICES AS NO 25.03 DEFINED IN CMS PUB. 15-I, SECTION 2148? IF YES, COMPLETE WORKSHEET D-9. 25.04 ARE YOU CLAIMING COSTS ON LINE 70 OF WORKSHEET A? IF YES, COMPLETE WORKSHEET D-2 NO 25.04 25.05 HAS YOUR FACILITY DIRECT GME FTE CAP (COLUMN 1) OR IME CAP (COLUMN 2) BEEN REDUCED UNDER NO 25.05 42 CFR 413.79(c)(3) OR 42 CFR 412.105(f)(1)(iv)(B)? ENTER 'Y' FOR YES AND 'N' FOR NO IN THE APPLICABLE COLUMNS. (SEE INSTRUCTIONS) 25.06 HAS YOUR FACILITY RECEIVED ADDITIONAL DIRECT GME FTE RESIDENT CAP SLOTS OR IME FTE 25.06 RESIDENT CAP SLOTS UNDER 42 CFR 413.79(c)(4) OR 42 CFR 412.105(f)(1)(iv)(C)? ENTER 'Y' FOR YES AND 'N' FOR NO IN THE APPLICABLE COLUMNS. (SEE INSTRUCTIONS) PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (05/2007) 05/29/2009 10:07 HOSPITAL AND HEALTH CARE COMPLEX IDENTIFICATION DATA WORKSHEET S-2 (CONTINUED) OTHER INFORMATION 26 IF THIS A SOLE COMMUNITY HOSPITAL (SCH), ENTER THE NUMBER OF PERIODS SCH STATUS IN EFFECT. 26 ENTER BEGINNING AND ENDING DATES OF SCH STATUS ON LINE 26.01. SUBSCRIPT LINE 26.01 FOR NUMBER OF PERIODS IN EXCESS OF ONE AND ENTER SUBSEQUENT DATES. 26.01 ENTER THE APPLICABLE SCH DATES: BEGINNING: ENDING: 26.01 26.03 IF THIS A SOLE COMMUNITY HOSPITAL (SCH) FOR ANY PART OF THE COST REPORTING PERIOD, ENTER 26.03 THE NUMBER OF PERIODS WITHIN THIS COST REPORTING PERIOD THAT SCH STATUS WAS IN EFFECT AND THE SCH WAS EITHER PHYSICALLY LOCATED OR CLASSIFIED IN A RURAL AREA. 26.04 IF LINE 26.03 COLUMN 1 IS GREATER THAN ONE ENTER THE EFFECTIVE DATES (SEE INSTRUCTIONS): 26.04 BEGINNING: ENDING: BEGINNING: ENDING: 27 DOES THIS HOSPITAL HAVE AN AGREEMENT UNDER EITHER SECTION 1883 OR SECTION 1913 NO 27 FOR SWING BEDS? IF YES, ENTER THE AGREEMENT DATE (mm/dd/yyyy) IN COLUMN 2. 28 IF THIS FACILITY CONTAINS A HOSPITAL-BASED SNF, ARE ALL PATIENTS UNDER MANAGED CARE 28 OR THERE WAS NO MEDICARE UTILIZATION ENTER 'Y', IF 'N' COMPLETE LINES 28.01 AND 28.02. 28.01 IF HOSPITAL BASED SNF ENTER APPROPRIATE TRANSITION PERIOD 1, 2, 3, OR 100 IN COL 1, ENTER 28.01 IN COLS 2 AND 3 THE WAGE INDEX ADJUSTMENT FACTOR BEFORE AND ON OR AFTER OCTOBER 1st 28.02 ENTER IN COL 1 THE HOSPITAL BASED SNF FACILITY SPECIFIC RATE (FROM YOUR F.I.) 28.02 If YOU HAVE NOT TRANSITIONED TO 100% PPS SNF PAYMENT. IN COL 2 ENTER THE FACILITY CLASSIFICATION URBAN(1) OR RURAL(2). IN COL 3, ENTER THE SNF MSA CODE OR TWO CHARACTER CODE IF A RURAL BASED FACILITY. IN COL 4, ENTER THE SNF CBSA CODE OR TWO CHARACTER CODE IF RURAL BASED FACILITY. A NOTICE PUBLISHED IN THE 'FEDERAL REGISTER' VOL. 68, NO. 149 AUGUST 4, 2003 PROVIDED FOR AN INCREASE IN THE RUG PAYMENTS BEGINNING 10/01/2003. CONGRESS EXPECTED THIS INCREASE TO BE USED FOR DIRECT PATIENT CARE AND RELATED EXPENSES. ENTER IN COLUMN 1 THE PERCENTAGE OF TOTAL EXPENSES FOR EACH CATEGORY TO TOTAL SNF REVENUE FROM WORKSHEET G-2, PART I, LINE 6, COLUMN 3. INDICATE IN COLUMN 2 'Y' FOR YES OR 'N' FOR NO IF THE SPENDING REFLECTS INCREASES ASSOCIATED WITH DIRECT PATIENT CARE AND RELATED EXPENSES FOR EACH CATEGORY. (SEE INSTRUCTIONS) 28.03 STAFFING 0.00 N 28.03 28.04 RECRUITMENT 0.00 N 28.04 28.05 RETENTION OF EMPLOYEES 0.00 N 28.05 28.06 TRAINING 0.00 N 28.06 28.07 OTHER (SPECIFY) 28.07 29 IS THIS A RURAL HOSPITAL WITH A CERTIFIED SNF WHICH HAS FEWER THAN 50 BEDS IN THE NO 29 AGGREGATE FOR BOTH COMPONENTS, USING THE SWING BED OPTIONAL METHOD OF REIMBURSEMENT? 30 DOES THIS HOSPITAL QUALIFY AS A RURAL PRIMARY CARE HOSPITAL (RPCH)/CRITICAL ACCESS NO 30 HOSPITAL (CAH)? SEE 42 CFR 485.606ff. 30.01 IF SO, IS THIS THE INITIAL 12 MONTH PERIOD FOR THE FACILITY OPERATED AS A RPCH/CAH? 30.01 SEE 42 CFR 413.70. 30.02 IF THIS FACILITY QUALIFIES AS AN RPCH/CAH, HAS IT ELECTED THE ALL-INCLUSIVE METHOD OF 30.02 PAYMENT FOR OUTPATIENT SERVICES? 30.03 IF THIS FACILITY QUALIFIES AS A CAH, IS IT ELIGIBLE FOR COST REIMBURSEMENT FOR AMBULANCE 30.03 SERVICES? IF YES, ENTER IN COLUMN 2 THE DATE OF ELIGIBILITY DETERMINATION (DATE MUST BE ON OR AFTER 12/21/2000) 30.04 IF THIS FACILITY QUALIFIES AS A CAH, IS IT ELIGIBLE FOR COST REIMBURSEMENT FOR I&R TRAINING 30.04 PROGRAMS? ENTER 'Y' FOR YES AND 'N' FOR NO. IF YES, THE GME ELIMINATION WOULD NOT BE ON WORKSHEET B, PART I, COLUMN 26 AND THE PROGRAM WOULD BE COST REIMBURSED. IF YES COMPLETE WORKSHEET D-2, PART II. 31 IS THIS A RURAL HOSPITAL QUALIFYING FOR AN EXCEPTION TO THE CRNA FEE SCHEDULE? NO 31 SEE 42 CFR 412.113(c). MISCELLANEOUS COST REPORTING INFORMATION 32 IS THIS AN ALL-INCLUSIVE RATE PROVIDER? IF YES, ENTER THE METHOD USED (A, B, OR E ONLY) NO 32 IN COLUMN 2. 33 IS THIS A NEW HOSPITAL UNDER 42 CFR 412.300 PPS CAPITAL? ENTER 'Y' FOR YES AND 'N' FOR NO 33 NO IN COLUMN 1. IF YES, FOR COST REPORTING PERIODS BEGINNING ON OR AFTER OCTOBER 1, 2002, DO YOU ELECT TO BE REIMBURSED AT 100% FEDERAL CAPITAL PAYMENT. ENTER 'Y' FOR YES AND 'N' FOR NO IN COLUMN 2. 34 IS THIS A NEW HOSPITAL UNDER 42 CFR 413.40(f)(1)(i) TEFRA? NO 34 35 HAVE YOU ESTABLISHED A NEW SUBPROVIDER I (EXLUDED UNIT) UNDER 42 CFR 413.40(f)(1)(i)? NO 35 V XVIII XIX PROSPECTIVE PAYMENT SYSTEM (PPS) - CAPITAL 1 2 3 36 DO YOU ELECT FULLY PROSPECTIVE PAYMENT METHODOLOGY FOR CAPITAL COSTS? NO YES NO 36 36.01 DOES YOUR FACILITY QUALIFY AND RECEIVE PAYMENT FOR DISPROPORTIONATE SHARE IN ACCORDANCE NO NO NO 36.01 WITH 42CFR412.320? 37 DO YOU ELECT HOLD HARMLESS PAYMENT METHODOLOGY FOR CAPITAL COSTS? NO NO NO 37 37.01 IF YOU ARE A HOLD HARMLESS PROVIDER, ARE YOU FILING ON THE BASIS OF 100% OF FEDERAL RATE? NO NO NO 37.01 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (05/2007) 05/29/2009 10:07 HOSPITAL AND HEALTH CARE COMPLEX IDENTIFICATION DATA WORKSHEET S-2 (CONTINUED) TITLE XIX INPATIENT HOSPITAL SERVICES 38 DO YOU HAVE TITLE XIX INPATIENT HOSPITAL SERVICES? YES 38 38.01 IS THIS HOSPITAL REIMBURSED FOR TITLE XIX THROUGH THE COST REPORT EITHER IN FULL OR IN PART? NO 38.01 38.02 DOES THE TITLE XIX PROGRAM REDUCE CAPITAL FOLLOWING THE MEDICARE METHODOLOGY? NO 38.02 38.03 ARE TITLE XIX NF PATIENTS OCCUPYING TITLE XVIII SNF BEDS (DUAL CERTIFICATION)? NO 38.03 38.04 DO YOU OPERATE AN ICF/MR FACILITY FOR PURPOSES OF TITLE XIX? NO 38.04 40 ARE THERE ANY RELATED ORGANIZATION OR HOME OFFICE COSTS AS DEFINED IN CMS PUB. 15-I, YES 15H032 40 CHAPTER 10? IF YES, AND THERE ARE HOME OFFICE COSTS, ENTER IN COLUMN 2 THE HOME OFFICE PROVIDER NUMBER. (SEE INSTRUCTIONS) IF THIS FACILITY IS PART OF A CHAIN ORGANIZATION, ENTER THE NAME AND ADDRESS OF THE HOME OFFICE. 40.01 NAME: PARKVIEW HEALTH SYSTEM, INC FI/CONTRACTOR'S NAME: NATIONAL GOVERNMENT SERVICEFI/CONTRACTOR'S NUMBER: 40.01 40.02 STREET: 10501 CORPORATE DRIVE P.O.BOX: 5600 40.02 40.03 CITY: STATE: IN ZIP CODE: 46895-5600 40.03 41 ARE PROVIDER BASED PHYSICIANS' COSTS INCLUDED IN WORKSHEET A? YES 41 42 ARE PHYSICAL THERAPY SERVICES PROVIDED BY OUTSIDE SUPPLIERS? YES 42 42.01 ARE OCCUPATIONAL THERAPY SERVICES PROVIDED BY OUTSIDE SUPPLIERS? YES 42.01 42.02 ARE SPEECH PATHOLOGY SERVICES PROVIDED BY OUTSIDE SUPPLIERS? NO 42.02 43 ARE RESPIRATORY THERAPY SERVICES PROVIDED BY OUTSIDE PROVIDERS? NO 43 44 IF YOU ARE CLAIMING COST FOR RENAL SERVICES ON WORKSHEET A, ARE THEY INPAT SERVICES ONLY? NO 44 45 HAVE YOU CHANGED YOUR COST ALLOCATION METHODOLOGY FROM THE PREVIOUSLY FILE COST REPORT? NO 45 SEE CMS PUB. 15-II, SECTION 3617. IF YES, ENTER THE APPROVAL DATE (mm/dd/yyyy) IN COLUMN 2. 45.01 WAS THERE A CHANGE IN THE STATISTICAL BASIS? 45.01 45.02 WAS THERE A CHANGE IN THE ORDER OF ALLOCATION? 45.02 45.03 WAS THERE A CHANGE TO THE SIMPLIFIED COST FINDING METHOD? 45.03 46 IF YOU ARE PARTICIPATING IN THE NHCMQ DEMONSTRATION PROJECT (MUST HAVE A HOSPITAL-BASED SNF) 46 DURING THIS COST REPORTING PERIOD, ENTER THE PHASE. IF THIS FACILITY CONTAINS A PROVIDER THAT QUALIFIES FOR AN EXEMPTION FROM THE APPLICATION OF THE LOWER OF COST OR CHARGES, ENTER A 'Y' FOR EACH COMPONENT AND TYPE OF SERVICE THAT QUALIFIES FOR THE EXEMPTION; ENTER 'N' IF NOT EXEMPT (SEE 42 CFR 413.13). OUTPATIENT OUTPATIENT OUTPATIENT PART A PART B ASC RADIOLOGY DIAGNOSTIC 1 2 3 4 5 47 HOSPITAL N N N N N 47 48 SUBPROVIDER I N N N N N 48 49 SKILLED NURSING FACILITY N N 49 50 HOME HEALTH AGENCY N N 50 52 DOES THIS HOSPITAL CLAIM EXPENDITURES FOR EXTRAORDINARY CIRCUMSTANCES IN ACCORDANCE WITH NO 52 42 CFR 412.348(e)? 52.01 IF YOU ARE A FULLY PROSPECTIVE OR HOLD HARMLESS PROVIDER ARE YOU ELIGIBLE FOR THE SPECIAL NO 52.01 EXCEPTION PAYMENT PURSUANT TO 42 CFR 412.348(g)? IF YES, COMPLETE L, PART IV. 53 IF THIS IS A MEDICARE DEPENDENT HOSPITAL (MDH), ENTER THE NUMBER OF PERIODS MDH STATUS IN 53 EFFECT. ENTER BEGINNING AND ENDING DATES OF MDH STATUS ON LINE 53.01. SUBSCRIPT LINE 53.01 FOR NUMBER OF PERIODS IN EXCESS OF ONE AND ENTER SUBSEQUENT DATES. 53.01 MDH PERIOD: BEGINNING: ENDING: 53.01 54 LIST AMOUNTS OF MALPRACTICE PREMIUMS AND PAID LOSSES: 54 PREMIUMS: PAID LOSSES: 37500 AND/OR SELF INSURANCE: 114654 54.01 ARE MALPRACTICE PREMIUMS AND PAID LOSSES REPORTED IN OTHER THAN THE ADMINISTRATIVE AND NO 54.01 GENERAL COST CENTER? IF YES, SUBMIT SUPPORTING SCHEDULE LISTING COST CENTERS AND AMOUNTS CONTAINED THEREIN. 55 DOES YOUR FACILITY QUALIFY FOR ADDITIONAL PROSPECTIVE PAYMENT IN ACCORDANCE WITH NO 55 42 CFR 412.107. ENTER 'Y' FOR YES AND 'N' FOR NO. DATE Y/N LIMIT Y/N FEES 0 1 2 3 4 56 ARE YOU CLAIMING AMBULANCE COSTS? IF YES, ENTER IN COL 2 THE PAYMENT LIMIT / / NO 0.00 NO 56 PROVIDED FROM YOUR FISCAL INTERMEDIARY. IF THIS IS FIRST YEAR OF OPERATIONS, NO ENTRY IS REQUIRED IN COL 2. IF COL 1 IS 'Y', ENTER 'Y' OR 'N' IN COL 3 WHETHER THIS IS YOUR FIRST YEAR OF OPERATIONS FOR RENDERING AMBULANCE SERVICES. ENTER IN COL 4, IF APPLICABLE, THE FEE SCHEDULES AMOUNTS FOR THE PERIOD BEGINNING ON OR AFTER 4/1/2002. 57 ARE YOU CLAIMING NURSING AND ALLIED HEALTH COSTS? NO 57 58 ARE YOU AN INPATIENT REHABILITATION FACILITY (IRF), OR DO YOU CONTAIN AN IRF SUBPROVIDER? NO 58 ENTER IN COLUMN 1 'Y' FOR YES AND 'N' FOR NO. IF YES HAVE YOU MADE THE ELECTION FOR 100% PPS REIMBURSEMENT? ENTER IN COLUMN 2 'Y' FOR YES AND 'N' FOR NO. THIS OPTION IS ONLY AVAILABLE FOR COST REPORTING PERIODS BEGINNING ON OR AFTER 1/1/2002 AND BEFORE 10/1/2002. 58.01 IF LINE 58 COLUMN 1 IS Y, DOES THE FACILITY HAVE A TEACHING PROGRAM IN THE MOST RECENT 58.01 COST REPORTING PERIOD ENDING ON OR BEFORE NOVEMBER 15, 2004? ENTER IN COLUMN 1 'Y' FOR YES OR 'N' FOR NO. IS THE FACILITY TRAINING RESIDENTS IN A NEW TEACHING PROGRAM IN ACCORDANCE WITH FR VOL 70, NO 156 DATED AUGUST 15, 2005 PAGE 47929? ENTER IN COLUMN 2 'Y' FOR YES OR 'N' FOR NO. IF COLUMN 2 IS Y, ENTER 1, 2, OR 3 RESPECTIVELY IN COLUMN 3 (SEE INSTRUCTIONS) IF THE CURRENT COST REPORTING PERIOD COVERS THE BEGINNING OF THE FOURTH ENTER 4 IN COLUMN 3, OR IF THE SUBSEQUENT ACADEMIC YEARS OF THE NEW TEACHING PROGRAM IN EXISTENCE, ENTER 5. (SEE INSTRUCTIONS) 59 ARE YOU A LONG TERM CARE HOSPITAL (LTCH), OR DO YOU CONTAIN A LTCH SUBPROVIDER? NO 59 ENTER IN COLUMN 1 'Y' FOR YES AND 'N' FOR NO. IF YES HAVE YOU MADE THE ELECTION FOR 100% PPS REIMBURSEMENT? ENTER IN COLUMN 2 'Y' FOR YES AND 'N' FOR NO. (SEE INSTRUCTIONS) PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (05/2007) 05/29/2009 10:07 HOSPITAL AND HEALTH CARE COMPLEX IDENTIFICATION DATA WORKSHEET S-2 (CONTINUED) 60 ARE YOU AN INPATIENT PSYCHIATRIC FACILITY (IPF), OR DO YOU CONTAIN AN IPF SUBPROVIDER? NO 60 ENTER IN COLUMN 1 'Y' FOR YES AND 'N' FOR NO. IF YES, IS THE IPF OR IPF SUBPROVIDER A NEW FACILITY? ENTER IN COLUMN 2 'Y' FOR YES AND 'N' FOR NO. (SEE INSTRUCTIONS) 60.01 IF LINE 60 COLUMN 1 IS Y, DOES THE FACILITY HAVE A TEACHING PROGRAM IN THE MOST RECENT 60.01 COST REPORTING PERIOD ENDING ON OR BEFORE NOVEMBER 15, 2004? ENTER 'Y' FOR YES OR 'N' FOR NO. IS THE FACILITY TRAINING RESIDENTS IN A NEW TEACHING PROGRAM IN ACCORDANCE WITH 42 CFR SEC. 412.424(d)(1)(iii)(2)? ENTER IN COLUMN 2 'Y' FOR YES OR 'N' FOR NO. IF COLUMN 2 IS Y, ENTER 1, 2, OR 3 RESPECTIVELY IN COLUMN 3 (SEE INSTRUCTIONS). IF THE CURRENT COST REPORTING PERIOD COVERS THE BEGINNING OF THE FOURTH ENTER 4 IN COLUMN 3, OR IF THE SUBSEQUENT ACADEMIC YEARS OF THE NEW TEACHING PROGRAM IN EXISTENCE, ENTER 5 (SEE INSTR.) MULTICAMPUS 61 DOES THE HOSPITAL HAVE A MULTICAMPUS? ENTER 'Y' FOR YES AND 'N' FOR NO. NO 61 IF LINE 61 IS YES, ENTER THE NAME IN COL. 0, COUNTY IN COL. 1, STATE IN COL. 2, ZIP IN COL. 3, CBSA IN COL. 4 AND FTE/CAMPUS IN COL. 5. FTE/ COUNTY: STATE: ZIP CODE CBSA CAMPUS 1 2 3 4 5 SETTLEMENT DATA 63 WAS THE COST REPORT FILED USING THE PS&R (EITHER IN ITS ENTIRETY OR FOR TOTAL CHARGES NO 63 AND DAYS ONLY)? ENTER 'Y' FOR YES AND 'N' FOR NO IN COLUMN 1. IF COLUMN 1 IS 'Y', ENTER THE 'PAID THROUGH' DATE OF THE PS&R IN COLUMN 2 (mm/dd/yyyy) PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:07 HOSPITAL AND HEALTH CARE COMPLEX STATISTICAL DATA WORKSHEET S-3 PART I ------------I/P DAYS / O/P VISITS / TRIPS----------- CAH LTCH OBS. NO. OF BED DAYS PATIENT TITLE TITLE NONCOVERED TITLE BEDS COMPONENT BEDS AVAILABLE HOURS V XVIII DAYS XIX ADMITTED 1 2 2.01 3 4 4.01 5 5.01 1 HOSPITAL ADULTS & PEDS, EXCL 36 13140 2192 291 1 SWING BED, OBSERV & HOSPICE DAYS 2 HMO 665 1216 2 3 HOSPITAL ADULTS & PEDS - 3 SWING BED SNF 4 HOSPITAL ADULTS & PEDS - 4 SWING BED NF 5 TOTAL ADULTS & PEDS 36 13140 2192 291 5 EXCL OBSERVATION BEDS 6 INTENSIVE CARE UNIT 6 7 CORONARY CARE UNIT 7 8 BURN INTENSIVE CARE UNIT 8 9 SURGICAL INTENSIVE CARE UNIT 9 10 OTHER SPECIAL CARE (SPECIFY) 10 11 NURSERY 108 11 12 TOTAL HOSPITAL 36 13140 2192 399 12 13 RPCH VISITS 13 14 SUBPROVIDER I 14 15 SKILLED NURSING FACILITY 15 16 NURSING FACILITY 16 17 OTHER LONG TERM CARE 17 18 HOME HEALTH AGENCY 18 20 ASC (DISTINCT PART) 20 21 HOSPICE (DISTINCT PART) 21 23 O/P REHAB PROVIDER 23 24 RHC I 24 25 TOTAL 36 25 26 OBSERVATION BED DAYS 89 12 26 27 AMBULANCE TRIPS 1284 27 28 EMPLOYEE DISCOUNT DAYS 28 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:07 HOSPITAL AND HEALTH CARE COMPLEX STATISTICAL DATA WORKSHEET S-3 PART I (CONTINUED) -----I/P DAYS / O/P VISITS / TRIPS---- ---INTERNS & RES FTES---- --FULL TIME EQUIV-- OBS. OBS. OBS. LESS I&R BEDS NOT TOTAL ALL BEDS BEDS NOT REPL NON- EMPLOYEES NONPAID COMPONENT ADMITTED PATIENTS ADMITTED ADMITTED TOTAL PHYS ANES NET ON PAYROLL WORKERS 5.02 6 6.01 6.02 7 8 9 10 11 1 HOSPITAL ADULTS & PEDS, EXCL. 5365 1 SWING BED, OBSERV & HOSPICE DAYS 2 HMO XIX 2 3 HOSPITAL ADULTS & PEDS - 3 SWING BED SNF 4 HOSPITAL ADULTS & PEDS - 4 SWING BED NF 5 TOTAL ADULTS & PEDS 5365 5 EXCL OBSERVATION BEDS 6 INTENSIVE CARE UNIT 6 7 CORONARY CARE UNIT 7 8 BURN INTENSIVE CARE UNIT 8 9 SURGICAL INTENSIVE CARE UNIT 9 10 OTHER SPECIAL CARE (SPECIFY) 10 11 NURSERY 895 11 12 TOTAL HOSPITAL 6260 244.00 12 13 RPCH VISITS 13 14 SUBPROVIDER I 14 15 SKILLED NURSING FACILITY 15 16 NURSING FACILITY 16 17 OTHER LONG TERM CARE 17 18 HOME HEALTH AGENCY 18 20 ASC (DISTINCT PART) 20 21 HOSPICE (DISTINCT PART) 21 23 O/P REHAB PROVIDER 23 24 RHC I 24 25 TOTAL 244.00 25 26 OBSERVATION BED DAYS 77 2534 55 2479 26 27 AMBULANCE TRIPS 27 28 EMPLOYEE DISCOUNT DAYS 78 28 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:07 HOSPITAL AND HEALTH CARE COMPLEX STATISTICAL DATA WORKSHEET S-3 PART I (CONTINUED) --------------DISCHARGES------------- TITLE TITLE TITLE TOTAL ALL COMPONENT V XVIII XIX PATIENTS 12 13 14 15 1 HOSPITAL ADULTS & PEDS, EXCL. 590 97 1730 1 SWING BED, OBSERV & HOSPICE DAYS 2 HMO XIX 2 3 HOSPITAL ADULTS & PEDS - 3 SWING BED SNF 4 HOSPITAL ADULTS & PEDS - 4 SWING BED NF 5 TOTAL ADULTS & PEDS 5 EXCL OBSERVATION BEDS 6 INTENSIVE CARE UNIT 6 7 CORONARY CARE UNIT 7 8 BURN INTENSIVE CARE UNIT 8 9 SURGICAL INTENSIVE CARE UNIT 9 10 OTHER SPECIAL CARE (SPECIFY) 10 11 NURSERY 11 12 TOTAL HOSPITAL 590 97 1730 12 13 RPCH VISITS 13 14 SUBPROVIDER I 14 15 SKILLED NURSING FACILITY 15 16 NURSING FACILITY 16 17 OTHER LONG TERM CARE 17 18 HOME HEALTH AGENCY 18 20 ASC (DISTINCT PART) 20 21 HOSPICE (DISTINCT PART) 21 23 O/P REHAB PROVIDER 23 24 RHC I 24 25 TOTAL 25 26 OBSERVATION BED DAYS 26 27 AMBULANCE TRIPS 27 28 EMPLOYEE DISCOUNT DAYS 28 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:07 HOSPITAL WAGE INDEX INFORMATION RECLASS. ADJUSTED PAID HOURS AVERAGE WORKSHEET S-3 OF SALARIES SALARIES RELATED HOURLY WAGE PART II PART II - WAGE DATA AMOUNT FROM WKST. (COL.1 + TO SALARY (COL.3 / DATA REPORTED A-6 COL.2) IN COL.3 COL.4) SOURCE SALARIES 1 2 3 4 5 6 1 TOTAL SALARIES 13626211 -310392 13315819 533384.00 24.96 1 2 NON-PHYSICIAN ANESTHETIST PART A 2 3 NON-PHYSICIAN ANESTHETIST PART B 3 4 PHYSICIAN - PART A 53330 53330 398.00 133.99 A-8-2 WORKPAPER 4 4.01 TEACHING PHYSICIAN SALARIES 4.01 5 PHYSICIAN - PART B 5 5.01 NON-PHYSICIAN - PART B 5.01 6 INTERNS & RESIDENTS (IN APPR PGM) 6 6.01 CONTRACT SERVICES, I&R 6.01 7 HOME OFFICE PERSONNEL 2470234 2470234 74940.00 32.96 A-8-1 WORKPAPER 7 8 SNF 8 8.01 EXCLUDED AREA SALARIES 1297482 23191 1320673 76918.00 17.17 HOURS WPS 8.01 OTHER WAGES & RELATED COSTS 9 CONTRACT LABOR 9 9.01 PHARMACY SERVICES UNDER CONTRACT 9.01 9.02 LABORATORY SERVICES UNDER CONTRACT 9.02 9.03 MANAGEMENT AND ADMINISTRATIVE SERVICES' 9.03 10 CONTRACT LABOR: PHYSICIAN PART A 10 10.01 TEACHING PHYSICIAN UNDER CONTRACT 10.01 11 HOME OFFICE SALARIES & WAGE REL COSTS 2470234 2470234 74940.00 32.96 A-8-1 WORKAPERS 11 12 HOME OFFICE: PHYSICIAN PART A 12 12.01 TEACHING PHYSICIAN SALARIES 12.01 WAGE-RELATED COSTS 13 WAGE RELATED COSTS (CORE) 3821954 3821954 CMS 339 13 14 WAGE RELATED COSTS (OTHER) CMS 339 14 15 EXCLUDED AREAS 410554 410554 CMS 339 15 16 NON-PHYSICIAN ANESTHETIST PART A CMS 339 16 17 NON-PHYSICIAN ANESTHETIST PART B CMS 339 17 18 PHYSICIAN PART A CMS 339 18 18.01 PART A TEACHING PHYSICIANS CMS 339 18.01 19 PHYSICIAN PART B CMS 339 19 19.01 WAGE RELATED COSTS (RHC/FQHC) 19.01 20 INTERNS & RESIDENTS (IN APPR PGM) CMS 339 20 OVERHEAD COSTS - DIRECT SALARIES 21 EMPLOYEE BENEFITS 1219142 -1219142 21 22 ADMINISTRATIVE & GENERAL 3309899 -181038 3128861 96830.00 32.31 22 22.01 ADMINISTRATIVE & GENERAL UNDER CONTACT 22.01 23 MAINTENANCE & REPAIRS 23 24 OPERATION OF PLANT 264635 27983 292618 12159.00 24.07 24 25 LAUNDRY & LINEN SERVICE 16953 16953 1488.00 11.39 25 26 HOUSEKEEPING 294772 14316 309088 26603.00 11.62 26 26.01 HOUSEKEEPING UNDER CONTRACT 26.01 27 DIETARY 333485 -245111 88374 6736.00 13.12 27 27.01 DIETARY UNDER CONTRACT 27.01 28 CAFETERIA 138136 138136 10852.00 12.73 28 29 MAINTENANCE OF PERSONNEL 29 30 NURSING ADMINISTRATION 154475 16335 170810 3913.00 43.65 30 31 CENTRAL SERVICES AND SUPPLY 1470 75938 77408 3144.00 24.62 31 32 PHARMACY 417422 44139 461561 11320.00 40.77 32 33 MEDICAL RECORDS & MEDICAL RECORDS LIBR 307104 307104 17198.00 17.86 33 34 SOCIAL SERVICE 34 35 OTHER GENERAL SERVICE 35 HOSPITAL WAGE INDEX INFORMATION WORKSHEET S-3 PART III RECLASS. ADJUSTED PAID HOURS AVERAGE OF SALARIES SALARIES RELATED HOURLY WAGE AMOUNT FROM WKST. (COL.1 + TO SALARY (COL.3 / PART III - HOSPITAL WAGE INDEX SUMMARY REPORTED A-6 COL.2) IN COL.3 COL.4) 1 2 3 4 5 1 NET SALARIES 11155977 -310392 10845585 458444.00 23.66 1 2 EXCLUDED AREA SALARIES 1297482 23191 1320673 76918.00 17.17 2 3 SUBTOTAL SALARIES (LINE 1 MINUS LINE 2) 9858495 -333583 9524912 381526.00 24.97 3 4 SUBTOTAL OTHER WAGES & REL COSTS 2470234 2470234 74940.00 32.96 4 5 SUBTOTAL WAGE-RELATED COSTS 3821954 3821954 40.13% 5 6 TOTAL (SUM OF LINES 3 THRU 5) 16150683 -333583 15817100 456466.00 34.65 6 7 NET SALARIES 7 8 EXCLUDED AREA SALARIES 8 9 SUBTOTAL SALARIES (LINE 7 MINUS LINE 8) 9 10 SUBTOTAL OTHER WAGES & REL COSTS 10 11 SUBTOTAL WAGE-RELATED COSTS 11 12 TOTAL (SUM OF LINES 9 THRU 11) 12 13 TOTAL OVERHEAD COSTS 5995300 -1004387 4990913 190243.00 26.23 13 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (4/2005) 05/29/2009 10:07 NHCMQ DEMONSTRATION STATISTICAL DATA WORKSHEET S-7 STATISTICAL DATA M3PI SERVICES SERVICES GROUP REVENUE PRIOR TO JANUARY 1 ON OR AFTER JANUARY 1 TOTAL CODE RATE DAYS RATE DAYS 1 2 3 3.01 4 4.01 5 1 RVC/RUC 1 2 RVB/RUB 2 3 RVA/RUA 3 3.01 RUX 3.01 3.02 RUL 3.02 4 RHD/RVC 4 5 RHC/RVB 5 6 RHB/RVA 6 6.01 RVX 6.01 6.02 RVL 6.02 7 RHA/RHC 7 8 RMC/RHB 8 9 RMB/RHA 9 9.01 RHX 9.01 9.02 RHL 9.02 10 RMA/RMC 10 11 RLB/RMB 11 12 RLA/RMA 12 12.01 RMX 12.01 12.02 RML 12.02 13 SE3/RLB 13 14 SE2/RLA 14 14.01 RLX 14.01 15 SE1/SE3 15 16 SSC/SE2 16 17 SSB/SE1 17 18 SSA/SSC 18 19 CD2/SSB 19 20 CD1/SSA 20 21 CC2 21 22 CC1 22 23 CB2 23 24 CB1 24 25 CA2 25 26 CA1 26 27 IB2 27 28 IB1 28 29 IA2 29 30 IA1 30 31 BB2 31 32 BB1 32 33 BA2 33 34 BA1 34 35 PE2 35 36 PE1 36 37 PD2 37 38 PD1 38 39 PC2 39 40 PC1 40 41 PB2 41 42 PB1 42 43 PA2 43 44 PA1 44 45 DEFAULT RATE 45 46 TOTAL 46 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (6/2003) 05/29/2009 10:07 HOSPITAL UNCOMPENSATED CARE DATA WORKSHEET S-10 UNCOMPENSATED CARE INFORMATION 1 DO YOU HAVE A WRITTEN CHARITY CARE POLICY? 1 2 ARE PATIENTS WRITE-OFFS IDENTIFIED AS CHARITY? IF YES ANSWER LINES 2.01 THRU 2.04 2 2.01 IS IT AT THE TIME OF ADMISSION? 2.01 2.02 IS IT AT THE TIME OF FIRST BILLING? 2.02 2.03 IS IT AFTER SOME COLLECTION EFFORT HAS BEEN MADE? 2.03 2.04 OTHER METHODS OF WRITE-OFFS (SPECIFY) 2.04 3 ARE CHARITY WRITE-OFFS MADE FOR PARTIAL BILLS? 3 4 ARE CHARITY DETERMINATION BASED UPON ADMINISTRATIVE JUDGMENT WITHOUT FINANCIAL DATA? 4 5 ARE CHARITY DETERMINATION BASED UPON INCOME DATA ONLY? 5 6 ARE CHARITY DETERMINATION BASED UPON NET WORTH DATA? 6 7 ARE CHARITY DETERMINATION BASED UPON INCOME AND NET WORTH DATA? 7 8 DOES YOUR ACCOUNTING SYSTEM SEPARATELY IDENTIFY BAD DEBT AND CHARITY CARE? IF YES ANSWER 8.01 8 8.01 DO YOU SEPARATELY ACCOUNT FOR INPATIENT AND OUTPATIENT SERVICES? 8.01 9 IS DISCERNING CHARITY FROM BAD DEBT A HIGH PRIORITY IN YOUR INSTITUTION? IF NO ANSWER 9.01 THRU 9.04 9 9.01 IS IT BECAUSE THERE IS NOT ENOUGH STAFF TO DETERMINE ELIGIBILITY? 9.01 9.02 IS IT BECAUSE THERE IS NO FINANCIAL INCENTIVE TO SEPARATE CHARITY FROM BAD DEBT? 9.02 9.03 IS IT BECAUSE THERE IS NO CLEAR DIRECTIVE POLICY ON CHARITY DETERMINATION? 9.03 9.04 IS IT BECAUSE YOUR INSTITUTION DOES NOT DEEM THE DISTINCTION IMPORTANT? 9.04 10 IF CHARITY DETERMINATIONS ARE MADE BASED UPON INCOME DATA, WHAT IS THE MAXIMUM INCOME THAT CAN BE EARNED 10 BY PATIENTS (SINGLE WITHOUT DEPENDENT) AND STILL DETERMINED TO BE A CHARITY WRITE-OFF? 11 IF CHARITY DETERMINATIONS ARE MADE BASED UPON INCOME DATA, IS THE INCOME DIRECTLY TIED TO FEDERAL POVERTY 11 LEVEL? IF YES ANSWER LINES 11 THRU 11.04 11.01 IS THE PERCENTAGE LEVEL USED LESS THAN 100% OF THE FEDERAL POVERTY LEVEL? 11.01 11.02 IS THE PERCENTAGE LEVEL USED BETWEEN 100% AND 150% OF THE FEDERAL POVERTY LEVEL? 11.02 11.03 IS THE PERCENTAGE LEVEL USED BETWEEN 150% AND 200% OF THE FEDERAL POVERTY LEVEL? 11.03 11.04 IS THE PERCENTAGE LEVEL USED GREATER THAN 200% OF THE FEDERAL POVERTY LEVEL? 11.04 12 ARE PARTIAL WRITE-OFFS GIVEN TO HIGHER INCOME PATIENTS ON A GRADUAL SCALE? 12 13 IS THERE CHARITY CONSIDERATION GIVEN TO HIGH NET WORTH PATIENTS WHO HAVE CATASTROPHIC OR OTHER 13 EXTRAORDINARY MEDICAL EXPENSES? 14 IS YOUR HOSPITAL STATE AND LOCAL GOVERNMENT OWNED? IF YES ANSWER LINE 14.01 14 14.01 DO YOU RECEIVE DIRECT FINANCIAL SUPPORT FROM THE GOVERNMENT ENTITY FOR THE PURPOSE OF PROVIDING 14.01 UNCOMPENSATED CARE? 14.02 WHAT PERCENTAGE OF THE AMOUNT ON LINE 14.01 IS FROM GOVERNMENT FUNDING? 14.02 15 DO YOU RECEIVE RESTRICTED GRANTS FOR RENDERING CARE TO CHARITY PATIENTS? 15 16 ARE OTHER NON-RESTRICTED GRANTS USED TO SUBSIDIZE CHARITY CARE? 16 17 REVENUE RELATED TO UNCOMPENSATED CARE 6268090 17 17.01 GROSS MEDICAID REVENUES 12638188 17.01 18 REVENUES FROM STATE AND LOCAL INDIGENT CARE PROGRAMS 18 19 REVENUE RELATED TO SCHIP (SEE INSTRUCTIONS) 19 20 RESTRICTED GRANTS 20 21 NON-RESTRICTED GRANTS 21 22 TOTAL GROSS UNCOMPENSATED CARE REVENUES 18906278 22 23 TOTAL CHARGES FOR PATIENTS COVERED BY STATE AND LOCAL INDIGENT CARE PROGRAMS 23 24 COST TO CHARGE RATIO 0.334854 24 25 TOTAL STATE AND LOCAL INDIGENT CARE PROGRAM COST 25 26 TOTAL SCHIP CHARGES FROM YOUR RECORDS 26 27 TOTAL SCHIP COST 27 28 TOTAL GROSS MEDICAID CHARGES FROM YOUR RECORDS 12638188 28 29 TOTAL GROSS MEDICAID COST 4231948 29 30 OTHER UNCOMPENSATED CARE CHARGES (FROM YOUR RECORDS) 6268090 30 31 UNCOMPENSATED CARE COST 2098895 31 32 TOTAL UNCOMPENSATED CARE COST TO THE HOSPITAL 4231948 32 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:07 RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES WORKSHEET A RECLASS. NET EXP RECLASSI- TRIAL ADJUST- FOR COST CENTER SALARIES OTHER TOTAL FICATIONS BALANCE MENTS ALLOCATION 1 2 3 4 5 6 7 GENERAL SERVICE COST CENTERS 1 0100 OLD CAP REL COSTS-BLDG & FIXT 1 2 0200 OLD CAP REL COSTS-MVBLE EQUIP 2 3 0300 NEW CAP REL COSTS-BLDG & FIXT 912961 912961 -760619 152342 720491 872833 3 4 0400 NEW CAP REL COSTS-MVBLE EQUIP 1702188 1702188 857112 2559300 4 5 0500 EMPLOYEE BENEFITS 1219142 4183908 5403050 -1219142 4183908 -732087 3451821 5 6 0600 ADMINISTRATIVE & GENERAL 3309899 4851858 8161757 249399 8411156 -3385038 5026118 6 7 0700 MAINTENANCE & REPAIRS 7 8 0800 OPERATION OF PLANT 264635 842809 1107444 27983 1135427 -2764 1132663 8 9 0900 LAUNDRY & LINEN SERVICE 145492 145492 16953 162445 162445 9 10 1000 HOUSEKEEPING 294772 74216 368988 14316 383304 -41096 342208 10 11 1100 DIETARY 333485 263342 596827 -446968 149859 -10921 138938 11 12 1200 CAFETERIA 247218 247218 -135569 111649 12 13 1300 MAINTENANCE OF PERSONNEL 13 14 1400 NURSING ADMINISTRATION 154475 1984 156459 16335 172794 172794 14 15 1500 CENTRAL SERVICES & SUPPLY 1470 16415 17885 155 18040 76955 94995 15 16 1600 PHARMACY 417422 1226154 1643576 -1134706 508870 -331623 177247 16 17 1700 MEDICAL RECORDS & LIBRARY 536303 536303 17 18 1800 SOCIAL SERVICE 18 20 2000 NONPHYSICIAN ANESTHETISTS 20 21 2100 NURSING SCHOOL 21 22 2200 I&R SERVICES-SALARY & FRINGES A 22 23 2300 I&R SERVICES-OTHER PRGM COSTS A 23 24 2400 PARAMED ED PRGM-(SPECIFY) 24 INPATIENT ROUTINE SERV COST CENTERS 25 2500 ADULTS & PEDIATRICS 2621398 285587 2906985 277945 3184930 3184930 25 33 3300 NURSERY 33 ANCILLARY SERVICE COST CENTERS 37 3700 OPERATING ROOM 899720 619232 1518952 88776 1607728 -373497 1234231 37 41 4100 RADIOLOGY-DIAGNOSTIC 782005 969763 1751768 -756122 995646 -137 995509 41 44 4400 LABORATORY 1365196 1365196 -1361 1363835 -275 1363560 44 46.30 4650 BLOOD CLOTTING FACTORS ADMIN CO 46.30 49 4900 RESPIRATORY THERAPY 422479 50328 472807 43973 516780 -56472 460308 49 50 5000 PHYSICAL THERAPY 638718 58969 697687 2923 700610 -7527 693083 50 51 5100 OCCUPATIONAL THERAPY 51 55 5500 MEDICAL SUPPLIES CHARGED TO PAT 1441873 1441873 -1663 1440210 -205 1440005 55 56 5600 DRUGS CHARGED TO PATIENTS 88597 88597 1172120 1260717 1260717 56 OUTPATIENT SERVICE COST CENTERS 60 6000 CLINIC 219006 332739 551745 23273 575018 -348120 226898 60 61 6100 EMERGENCY 750103 67926 818029 37181 855210 124953 980163 61 62 6200 OBSERVATION BEDS (NON-DISTINCT 62 63.50 6310 RHC 63.50 63.60 6320 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 6500 AMBULANCE SERVICES 1211401 275472 1486873 37623 1524496 -281976 1242520 65 71 7100 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 8510 PANCREAS ACQUISITION 85.01 85.02 8520 INTESTINAL ACQUISITION 85.02 88 8800 INTEREST EXPENSE 5728 5728 -5728 88 95 SUBTOTALS 13540130 18080549 31620679 -367948 31252731 -3391493 27861238 95 NONREIMBURSABLE COST CENTERS 96 9600 GIFT, FLOWER, COFFEE SHOP & CAN 96 98 9800 PHYSICIANS' PRIVATE OFFICES 544774 544774 544774 -544769 5 98 100 7950 OCC HEALTH -75783 -75783 133270 57487 57487 100 100.01 7951 FOUNDATION 80004 80004 80004 80004 100.01 100.02 7952 KIDS KAMPUS 43606 -43596 10 104014 104024 104024 100.02 100.03 7953 COMMUNITY HEALTH IMPROVEMENT 725565 725565 663 726228 726228 100.03 100.04 7954 HUNTINGTON COLLEGE NURSE 42475 -13162 29313 36 29349 29349 100.04 100.05 7955 MISC CATERING 129965 129965 129965 100.05 100.06 7956 NON-ALLOWED OFFICE SPACE 100.06 101 TOTAL 13626211 19298351 32924562 32924562 -3936262 28988300 101 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:07 RECLASSIFICATIONS WORKSHEET A-6 PAGE 1 EXPLANATION OF RECLASSIFICATION ENTRY CODE ------------------------------ INCREASE ------------------------------ COST CENTER LINE # SALARY OTHER 1 2 3 4 5 1 CAFETERIA & CATERING RECLASS A CAFETERIA 12 138136 109082 1 2 A KIDS KAMPUS 100.02 58697 46351 2 3 A MISC CATERING 100.05 72620 57345 3 4 INTEREST RECLASS B NEW CAP REL COSTS-MVBLE EQUIP 4 5728 4 5 DRUG RECLASS C DRUGS CHARGED TO PATIENTS 56 1178845 5 6 DEPRECIATION RECLASS D NEW CAP REL COSTS-MVBLE EQUIP 4 780299 6 7 BUILDING & EQUIPMENT RENTAL RECLASS E NEW CAP REL COSTS-MVBLE EQUIP 4 873146 7 8 E 8 9 E 9 10 E 10 11 E 11 12 E 12 13 E 13 14 INSURANCE RECLASS F NEW CAP REL COSTS-BLDG & FIXT 3 19680 14 15 F NEW CAP REL COSTS-MVBLE EQUIP 4 43015 15 16 LAUNDRY RECLASS G LAUNDRY & LINEN SERVICE 9 16953 16 17 HOME OFFICE SALARY RECLASS H CENTRAL SERVICES & SUPPLY 15 75783 17 18 H ADMINISTRATIVE & GENERAL 6 517241 18 19 H MEDICAL RECORDS & LIBRARY 17 307104 19 20 H AMBULANCE SERVICES 65 151236 20 21 PTO RECLASS I ADMINISTRATIVE & GENERAL 6 350084 21 22 I OPERATION OF PLANT 8 27983 22 23 I HOUSEKEEPING 10 31269 23 24 I DIETARY 11 35263 24 25 I NURSING ADMINISTRATION 14 16335 25 26 I CENTRAL SERVICES & SUPPLY 15 155 26 27 I PHARMACY 16 44139 27 28 I ADULTS & PEDIATRICS 25 277974 28 29 I OPERATING ROOM 37 95138 29 30 I RADIOLOGY-DIAGNOSTIC 41 82879 30 31 I RESPIRATORY THERAPY 49 44680 31 32 I PHYSICAL THERAPY 50 67539 32 33 I CLINIC 60 23273 33 34 I EMERGENCY 61 79321 34 35 I AMBULANCE SERVICES 65 43445 35 36 SUBTOTAL 1888770 3781968 36 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:07 RECLASSIFICATIONS WORKSHEET A-6 PAGE 1 EXPLANATION OF CODE ------------------------------ DECREASE ------------------------------ WKST A-7 RECLASSIFICATION ENTRY COST CENTER LINE # SALARY OTHER REF. 1 6 7 8 9 10 1 CAFETERIA & CATERING RECLASS A DIETARY 11 269453 212778 1 2 A 2 3 A 3 4 INTEREST RECLASS B INTEREST EXPENSE 88 5728 11 4 5 DRUG RECLASS C PHARMACY 16 1178845 5 6 DEPRECIATION RECLASS D NEW CAP REL COSTS-BLDG & FIXT 3 780299 9 6 7 BUILDING & EQUIPMENT RENTAL RECLA E ADMINISTRATIVE & GENERAL 6 37990 10 7 8 E ADULTS & PEDIATRICS 25 29 8 9 E OPERATING ROOM 37 6298 9 10 E RADIOLOGY-DIAGNOSTIC 41 807968 10 11 E RESPIRATORY THERAPY 49 78 11 12 E PHYSICAL THERAPY 50 15600 12 13 E AMBULANCE SERVICES 65 5183 13 14 INSURANCE RECLASS F ADMINISTRATIVE & GENERAL 6 62695 12 14 15 F 12 15 16 LAUNDRY RECLASS G HOUSEKEEPING 10 16953 16 17 HOME OFFICE SALARY RECLASS H CENTRAL SERVICES & SUPPLY 15 75783 17 18 H ADMINISTRATIVE & GENERAL 6 517241 18 19 H MEDICAL RECORDS & LIBRARY 17 307104 19 20 H AMBULANCE SERVICES 65 151236 20 21 PTO RECLASS I EMPLOYEE BENEFITS 5 1219142 21 22 I KIDS KAMPUS 100.02 1034 22 23 I 23 24 I 24 25 I 25 26 I 26 27 I 27 28 I 28 29 I 29 30 I 30 31 I 31 32 I 32 33 I 33 34 I 34 35 I 35 36 SUBTOTAL 2175059 3496378 36 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:07 RECLASSIFICATIONS WORKSHEET A-6 PAGE 2 EXPLANATION OF RECLASSIFICATION ENTRY CODE ------------------------------ INCREASE ------------------------------ COST CENTER LINE # SALARY OTHER 1 2 3 4 5 1 I COMMUNITY HEALTH IMPROVEMENT 100.03 663 1 2 I HUNTINGTON COLLEGE NURSE 100.04 36 2 3 SALARY RECLASS J ADMINISTRATIVE & GENERAL 6 13881 3 4 J DIETARY 11 10921 4 5 OCC HEALTH RECLASS K OCC HEALTH 100 133270 5 6 K 6 7 K 7 8 K 8 9 K 9 10 K 10 11 K 11 12 K 12 13 K 13 14 K 14 15 K 15 16 K 16 17 K 17 18 K 18 19 K 19 20 K 20 21 21 22 22 23 23 24 24 25 25 26 26 27 27 28 28 29 29 30 30 31 31 32 32 33 33 34 34 35 35 36 TOTAL RECLASSIFICATIONS 1889469 3940040 36 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:07 RECLASSIFICATIONS WORKSHEET A-6 PAGE 2 EXPLANATION OF CODE ------------------------------ DECREASE ------------------------------ WKST A-7 RECLASSIFICATION ENTRY COST CENTER LINE # SALARY OTHER REF. 1 6 7 8 9 10 1 I 1 2 I 2 3 SALARY RECLASS J ADMINISTRATIVE & GENERAL 6 13881 3 4 J DIETARY 11 10921 4 5 OCC HEALTH RECLASS K LABORATORY 44 1361 5 6 K AMBULANCE SERVICES 65 639 6 7 K EMERGENCY 61 42140 7 8 K DRUGS CHARGED TO PATIENTS 56 6657 8 9 K DRUGS CHARGED TO PATIENTS 56 68 9 10 K MEDICAL SUPPLIES CHARGED TO P 55 1663 10 11 K RESPIRATORY THERAPY 49 609 11 12 K RADIOLOGY-DIAGNOSTIC 41 3878 12 13 K RADIOLOGY-DIAGNOSTIC 41 22890 13 14 K RADIOLOGY-DIAGNOSTIC 41 774 14 15 K RADIOLOGY-DIAGNOSTIC 41 3491 15 16 K RESPIRATORY THERAPY 49 20 16 17 K PHYSICAL THERAPY 50 31121 17 18 K PHYSICAL THERAPY 50 17750 18 19 K PHYSICAL THERAPY 50 145 19 20 K OPERATING ROOM 37 64 20 21 21 22 22 23 23 24 24 25 25 26 26 27 27 28 28 29 29 30 30 31 31 32 32 33 33 34 34 35 35 36 TOTAL RECLASSIFICATIONS 2199861 3629648 36 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:07 ANALYSIS OF CHANGES DURING COST REPORTING WORKSHEET A-7 PERIOD IN CAPITAL ASSET BALANCES OF HOSPITAL PARTS I & II AND HOSPITAL HEALTH CARE COMPLEX CERTIFIED TO PARTICIPATE IN HEALTH CARE PROGRAMS PART I - ANALYSIS OF CHANGES IN OLD CAPITAL ASSET BALANCES --------- ACQUISITIONS -------- DISPOSALS FULLY BEGINNING AND ENDING DEPRECIATED DESCRIPTION BALANCES PURCHASE DONATION TOTAL RETIREMENTS BALANCE ASSETS 1 2 3 4 5 6 7 1 LAND 1 2 LAND IMPROVEMENTS 2 3 BUILDINGS AND FIXTURES 3 4 BUILDING IMPROVEMENTS 4 5 FIXED EQUIPMENT 5 6 MOVABLE EQUIPMENT 234552 234552 234552 6 7 SUBTOTAL 234552 234552 234552 7 8 RECONCILING ITEMS 8 9 TOTAL 234552 234552 234552 9 PART II - ANALYSIS OF CHANGES IN NEW CAPITAL ASSET BALANCES --------- ACQUISITIONS -------- DISPOSALS FULLY BEGINNING AND ENDING DEPRECIATED DESCRIPTION BALANCES PURCHASE DONATION TOTAL RETIREMENTS BALANCE ASSETS 1 2 3 4 5 6 7 1 LAND 1 2 LAND IMPROVEMENTS 121369 13611 13611 134980 10400 2 3 BUILDINGS AND FIXTURES 1092761 333803 333803 1426564 3 4 BUILDING IMPROVEMENTS 4 5 FIXED EQUIPMENT 931703 54974 54974 986677 5 6 MOVABLE EQUIPMENT 7186209 246861 246861 24900 7408170 2830487 6 7 SUBTOTAL 9332042 649249 649249 24900 9956391 2840887 7 8 RECONCILING ITEMS -795036 -703730 -91306 8 9 TOTAL 10127078 649249 649249 728630 10047697 2840887 9 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:07 PART III - RECONCILIATION OF CAPITAL COST CENTERS WORKSHEET A-7 PARTS III & IV ---------- COMPUTATION OF RATIOS ---------- ------ ALLOCATION OF OTHER CAPITAL ------- GROSS OTHER GROSS CAPITALIZED ASSETS CAPITAL- DESCRIPTION ASSETS LEASES FOR RATIO INSURANCE TAXES RELATED TOTAL RATIO COSTS 1 2 3 4 5 6 7 8 1 OLD CAP REL COSTS-BLDG & FIXT .000000 1 2 OLD CAP REL COSTS-MVBLE EQUIP 234552 234552 .023016 2 3 NEW CAP REL COSTS-BLDG & FIXT 2548221 2548221 .250048 3 4 NEW CAP REL COSTS-MVBLE EQUIP 7408169 7408169 .726936 4 5 TOTAL 10190942 10190942 1.000000 5 ---------------------- SUMMARY OF OLD AND NEW CAPITAL ---------------------- OTHER DEPREC- CAPITAL- DESCRIPTION IATION LEASE INTEREST INSURANCE TAXES RELATED TOTAL COSTS 9 10 11 12 13 14 15 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 853153 19680 872833 3 4 NEW CAP REL COSTS-MVBLE EQUIP 1643139 873146 43015 2559300 4 5 TOTAL 2496292 873146 62695 3432133 5 PART IV - RECONCILIATION OF AMOUNTS FROM WORKSHEET A, COLUMN 2, LINES 1 THRU 4 ---------------------- SUMMARY OF OLD AND NEW CAPITAL ---------------------- OTHER DEPREC- CAPITAL- DESCRIPTION IATION LEASE INTEREST INSURANCE TAXES RELATED TOTAL COSTS 9 10 11 12 13 14 15 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 912961 912961 3 4 NEW CAP REL COSTS-MVBLE EQUIP 4 5 TOTAL 912961 912961 5 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 ADJUSTMENTS TO EXPENSES WORKSHEET A-8 EXPENSE CLASSIFICATION ON WORKSHEET A TO/ FROM WHICH THE AMOUNT IS TO BE ADJUSTED WKST A-7 DESCRIPTION BASIS AMOUNT COST CENTER LINE NO. REF 1 2 3 4 5 1 INVESTMENT INCOME-OLD BLDGS & FIXTURES OLD CAP REL COSTS-BLDG & FIXT 1 1 2 INVESTMENT INCOME-OLD MOVABLE EQUIPMENT OLD CAP REL COSTS-MVBLE EQUIP 2 2 3 INVESTMENT INCOME-NEW BLDGS & FIXTURES NEW CAP REL COSTS-BLDG & FIXT 3 3 4 INVESTMENT INCOME-NEW MOVABLE EQUIPMENT B -5728 NEW CAP REL COSTS-MVBLE EQUIP 4 11 4 5 INVESTMENT INCOME-OTHER 5 6 TRADE, QUANTITY, AND TIME DISCOUNTS 6 7 REFUNDS AND REBATES OF EXPENSES 7 8 RENTAL OF PROVIDER SPACE BY SUPPLIERS 8 9 TELEPHONE SERVICES (PAY STATIONS EXCL) A -22416 ADMINISTRATIVE & GENERAL 6 9 10 TELEVISION AND RADIO SERVICE A -189 OPERATION OF PLANT 8 10 11 PARKING LOT 11 12 PROVIDER-BASED PHYSICIAN ADJUSTMENT WKST A-8-2 -31287 12 13 SALE OF SCRAP, WASTE, ETC. 13 14 RELATED ORGANIZATION TRANSACTIONS WKST A-8-1 560751 14 15 LAUNDRY AND LINEN SERVICE 15 16 CAFETERIA - EMPLOYEES AND GUESTS A -66072 CAFETERIA 12 16 17 RENTAL OF QUARTERS TO EMPLOYEES & OTHERS 17 18 SALE OF MEDICAL AND SURGICAL SUPPLIES TO OTHER THAN PATIENTS 18 19 SALE OF DRUGS TO OTHER THAN PATIENTS 19 20 SALE OF MEDICAL RECORDS AND ABSTRACTS 20 21 NURSING SCHOOL (TUITION,FEES,BOOKS,ETC.) 21 22 VENDING MACHINES A -10921 DIETARY 11 22 23 INCOME FROM IMPOSITION OF INTEREST, FINANCE OR PENALTY CHARGES 23 24 INTEREST EXP ON MEDICARE OVERPAYMENTS & BORROWINGS TO REPAY MEDICARE OVERPAYMENT 24 25 ADJ FOR RESPIRATORY THERAPY COSTS IN WKST EXCESS OF LIMITATION - HOSPITAL A-8-4 RESPIRATORY THERAPY 49 25 26 ADJ FOR PHYSICAL THERAPY COSTS IN WKST EXCESS OF LIMITATION - HOSPITAL A-8-4 PHYSICAL THERAPY 50 26 27 ADJ FOR HHA PHYSICAL THERAPY COSTS IN WKST EXCESS OF LIMITATION A-8-3 HOME HEALTH AGENCY 71 27 28 UTIL REVIEW-PHYSICIANS' COMPENSATION UTILIZATION REVIEW-SNF 89 28 29 DEPRECIATION--OLD BUILDINGS & FIXTURES OLD CAP REL COSTS-BLDG & FIXT 1 29 30 DEPRECIATION--OLD MOVABLE EQUIPMENT OLD CAP REL COSTS-MVBLE EQUIP 2 30 31 DEPRECIATION--NEW BUILDINGS & FIXTURES NEW CAP REL COSTS-BLDG & FIXT 3 31 32 DEPRECIATION--NEW MOVABLE EQUIPMENT NEW CAP REL COSTS-MVBLE EQUIP 4 32 33 NON-PHYSICIAN ANESTHETIST NONPHYSICIAN ANESTHETISTS 20 33 34 PHYSICIANS' ASSISTANT 34 35 ADJ FOR OCCUPATIONAL THERAPY COSTS IN WKST EXCESS OF LIMITATION - HOSPITAL WKST A-8-4 OCCUPATIONAL THERAPY 51 35 36 ADJ FOR SPEECH PATHOLOGY COSTS IN WKST EXCESS OF LIMITATION - HOSPITAL WKST A-8-4 36 37 EMS CLASS REVENUE B -1900 AMBULANCE SERVICES 65 37 37.01 TELEPHONE SERVICES A -4261 EMPLOYEE BENEFITS 5 37.01 37.02 TELEVISION OFFSET - DEP A -194 NEW CAP REL COSTS-MVBLE EQUIP 4 9 37.02 37.03 MISC INCOME B -295 ADMINISTRATIVE & GENERAL 6 37.03 37.07 PHARMACY REBATE B -5520 PHARMACY 16 37.07 37.08 FITNESS CENTER REVENUE B -50388 RESPIRATORY THERAPY 49 37.08 37.11 CLINC PHYS OFFICE EXP. REV B -146701 CLINIC 60 37.11 37.12 ATHLETIC TRAINER REV B -7062 PHYSICAL THERAPY 50 37.12 37.13 LAB MISC REV B -275 LABORATORY 44 37.13 37.14 COMMUNICATION SAMARITAN REV B -162096 ADMINISTRATIVE & GENERAL 6 37.14 37.18 MISC. REV B -2041 OPERATION OF PLANT 8 37.18 37.20 DIAG RAD MISC REV B -137 RADIOLOGY-DIAGNOSTIC 41 37.20 37.21 HOUSKEEPING MISC. REV B -41096 HOUSEKEEPING 10 37.21 37.22 OR - REBATES B -205 MEDICAL SUPPLIES CHARGED TO PAT 55 37.22 37.23 PROFESSIONAL AND APPLICATION FEES B -3250 ADMINISTRATIVE & GENERAL 6 37.23 37.24 VENDING - EH&W A -3353 EMPLOYEE BENEFITS 5 37.24 37.25 VENDING - PLANT A -534 OPERATION OF PLANT 8 37.25 37.26 RENT EXPENSE OFFSET A -1685560 ADMINISTRATIVE & GENERAL 6 37.26 37.27 RENT EXPENSE OFFSET A -201419 CLINIC 60 37.27 37.28 RENT EXPENSE OFFSET A -33272 AMBULANCE SERVICES 65 37.28 37.30 PHARMACY EMPLOYEE RX PURCHASES A -326103 PHARMACY 16 37.30 37.31 PHYSICIAN RECRUITMENT A -23674 ADMINISTRATIVE & GENERAL 6 37.31 37.33 TELEPHONE SERVICES - DEP A -2583 NEW CAP REL COSTS-MVBLE EQUIP 4 9 37.33 37.34 HUMAN RESOURCES OTHER REVENUE A -721239 EMPLOYEE BENEFITS 5 37.34 37.35 GUEST MEAL OFFSET A -69497 CAFETERIA 12 37.35 37.36 CONSULTING PT REVENUE B -465 PHYSICAL THERAPY 50 37.36 37.37 LOBBY % OF DUES & SUBSCRIPTIONS A -4482 ADMINISTRATIVE & GENERAL 6 37.37 37.38 ANESTHESIA SERVICES A -358494 OPERATING ROOM 37 37.38 37.39 MEDICAL DIRECTOR OFFSET A -93628 ADMINISTRATIVE & GENERAL 6 37.39 37.40 LIQUOR EXPENSE A -1060 ADMINISTRATIVE & GENERAL 6 37.40 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 ADJUSTMENTS TO EXPENSES WORKSHEET A-8 EXPENSE CLASSIFICATION ON WORKSHEET A TO/ FROM WHICH THE AMOUNT IS TO BE ADJUSTED WKST A-7 DESCRIPTION BASIS AMOUNT COST CENTER LINE NO. REF 1 2 3 4 5 37.44 OUTSOURCED TRANSCRIPTION ADD BACK A 135153 EMERGENCY 61 37.44 37.45 INTERUNIT SUBSIDY-OFFSET A -544769 PHYSICIANS' PRIVATE OFFICES 98 37.45 38 38 39 39 40 40 41 41 42 42 43 43 44 44 45 45 46 46 47 47 48 48 49 49 50 TOTAL -3936262 50 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:07 STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS AND HOME OFFICE COSTS WORKSHEET A-8-1 A. COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS OR THE CLAIMING OF HOME OFFICE COSTS: AMOUNT OF AMOUNT (INCL NET ADJ- WKST LINE ALLOWABLE IN WKST A, USTMENTS A-7 NO. COST CENTER EXPENSE ITEMS COST COL 5) REF 1 2 3 4 5 6 7 1 15 CENTRAL SERVICES & SUPPLY HOME OFFICE ALLOCATION 76955 76955 1 2 5 EMPLOYEE BENEFITS HOME OFFICE ALLOCATION 27101 27101 2 3 6 ADMINISTRATIVE & GENERAL HOME OFFICE ALLOCATION 3670011 5058588 -1388577 3 4 5 EMPLOYEE BENEFITS HOME OFFICE ALLOCATION 728665 807420 -78755 4 4.01 17 MEDICAL RECORDS & LIBRARY HOME OFFICE ALLOCATION 536303 536303 4.01 4.02 5 EMPLOYEE BENEFITS HOME OFFICE ALLOCATION 95304 95304 4.02 4.03 65 AMBULANCE SERVICES HOME OFFICE ALLOCATION 246804 -246804 4.03 4.04 5 EMPLOYEE BENEFITS HOME OFFICE ALLOCATION 46884 -46884 4.04 4.05 3 NEW CAP REL COSTS-BLDG & FIXT HOME OFFICE ALLOCATION 720491 720491 9 4.05 4.06 4 NEW CAP REL COSTS-MVBLE EQUIP HOME OFFICE ALLOCATION 865617 865617 9 4.06 5 TOTALS 6720447 6159696 560751 5 B. INTERRELATIONSHIP OF RELATED ORGANIZATION(S) AND/OR HOME OFFICE: THE SECRETARY, BY VIRTUE OF 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. THE INFORMATION IS USED BY THE HEALTH CARE FINANCING ADMINISTRATION AND ITS INTERMEDIARIES 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 REQUESTED INFORMATION, THE COST REPORT IS CONSIDERED INCOMPLETE AND NOT ACCEPTABLE FOR PURPOSES OF CLAIMING REIMBURSEMENT UNDER TITLE XVIII. -------- RELATED ORGANIZATION(S) AND/OR HOME OFFICE ---------- PERCENT PERCENT SYMBOL NAME OF NAME OF TYPE OF (1) OWNERSHIP OWNERSHIP BUSINESS 1 2 3 4 5 6 1 B PARKVIEW HEALTH SYSTEM, INC. HOME OFFICE 1 2 2 3 3 4 4 5 5 (1) USE THE FOLLOWING SYMBOLS TO INDICATE THE 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. G. OTHER (FINANCIAL OR NON-FINANCIAL) SPECIFY: PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:07 PROVIDER-BASED PHYSICIAN ADJUSTMENTS WORKSHEET A-8-2 WKST TOTAL PHYSICIAN/ UNAD- PERCENT A COST CENTER/ REMUNERA- PROFES- PROVIDER JUSTED OF UNAD- LINE PHYSICIAN IDENTIFIER TION INCL SIONAL PROVIDER RCE COMPONENT RCE JUSTED NO. FRINGES COMPONENT COMPONENT AMOUNT HOURS LIMIT RCE LIMIT 1 2 3 4 5 6 7 8 9 1 37 OPERATING ROOM NORTHEAST INDIANA A 53330 53330 200300 398 38327 1916 2 49 RESPIRATORY THERAPY J.C. MATHEWS 6084 6084 3 61 EMERGENCY PROFESSIONAL EMERGE 10200 10200 101 TOTAL 69614 16284 53330 398 38327 1916 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:07 PROVIDER-BASED PHYSICIAN ADJUSTMENTS WORKSHEET A-8-2 WKST COST OF PROVIDER PHYSICIAN PROVIDER A COST CENTER/ MEMBERSHIP COMPONENT COST OF COMPONENT ADJUSTED RCE LINE PHYSICIAN IDENTIFIER & CONTIN. SHARE OF MALPRACTICE SHARE OF RCE DIS- ADJUST- NO. EDUCATION COLUMN 12 INSURANCE COLUMN 14 LIMIT ALLOWANCE MENT 10 11 12 13 14 15 16 17 18 1 37 OPERATING ROOM NORTHEAST INDIANA A 38327 15003 15003 2 49 RESPIRATORY THERAPY J.C. MATHEWS 6084 3 61 EMERGENCY PROFESSIONAL EMERGE 10200 101 TOTAL 38327 15003 31287 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/29/2009 10:07 COST ALLOCATION - GENERAL SERVICE COSTS WORKSHEET B PART I NET EXP NEW CAP NEW CAP EMPLOYEE ADMINIS- OPERATION LAUNDRY COST CENTER DESCRIPTION FOR COST BLDGS & MOVABLE BENEFITS SUBTOTAL TRATIVE & OF PLANT & LINEN ALLOCATION FIXTURES EQUIPMENT GENERAL SERVICE 0 3 4 5 5A 6 8 9 GENERAL SERVICE COST CENTERS 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 872833 872833 3 4 NEW CAP REL COSTS-MVBLE EQUIP 2559300 2559300 4 5 EMPLOYEE BENEFITS 3451821 992 3452813 5 6 ADMINISTRATIVE & GENERAL 5026118 57744 605813 811315 6500990 6500990 6 7 MAINTENANCE & REPAIRS 7 8 OPERATION OF PLANT 1132663 230594 104928 75876 1544061 446382 1990443 8 9 LAUNDRY & LINEN SERVICE 162445 4729 4396 171570 49600 16131 237301 9 10 HOUSEKEEPING 342208 3849 1270 80147 427474 123581 13130 15622 10 11 DIETARY 138938 36777 21531 22916 220162 63648 125454 1430 11 12 CAFETERIA 111649 8345 35819 155813 45045 28466 1011 12 13 MAINTENANCE OF PERSONNEL 13 14 NURSING ADMINISTRATION 172794 44291 217085 62758 14 15 CENTRAL SERVICES & SUPPLY 94995 19208 14767 20072 149042 43087 65522 4428 15 16 PHARMACY 177247 8683 223873 119684 529487 153073 29620 16 17 MEDICAL RECORDS & LIBRARY 536303 4796 79633 620732 179451 16361 17 18 SOCIAL SERVICE 18 20 NONPHYSICIAN ANESTHETISTS 20 21 NURSING SCHOOL 21 22 I&R SERVICES-SALARY & FRINGES A 22 23 I&R SERVICES-OTHER PRGM COSTS A 23 24 PARAMED ED PRGM-(SPECIFY) 24 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 3184930 189148 322869 751813 4448760 1286119 645221 89122 25 33 NURSERY 767 767 222 2616 4739 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 1234231 72051 589640 257969 2153891 622681 245779 29791 37 41 RADIOLOGY-DIAGNOSTIC 995509 90304 220554 224266 1530633 442500 308045 18868 41 44 LABORATORY 1363560 13682 1377242 398155 46673 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 49 RESPIRATORY THERAPY 460308 6210 59900 121135 647553 187205 21183 49 50 PHYSICAL THERAPY 693083 57692 35764 183134 969673 280329 196798 15820 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO PAT 1440005 1440005 416300 55 56 DRUGS CHARGED TO PATIENTS 1260717 1260717 364468 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 226898 97557 62823 387278 111961 8356 60 61 EMERGENCY 980163 38491 35505 215071 1269230 366929 131301 38987 61 62 OBSERVATION BEDS (NON-DISTINCT 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 1242520 26696 225329 286168 1780713 514797 91065 9127 65 71 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 PANCREAS ACQUISITION 85.01 85.02 INTESTINAL ACQUISITION 85.02 95 SUBTOTALS 27861238 870758 2559300 3396528 27802878 6158291 1983365 237301 95 NONREIMBURSABLE COST CENTERS 96 GIFT, FLOWER, COFFEE SHOP & CAN 2075 2075 600 7078 96 98 PHYSICIANS' PRIVATE OFFICES 5 5 1 98 100 OCC HEALTH 57487 57487 16619 100 100.01FOUNDATION 80004 80004 23129 100.01 100.02KIDS KAMPUS 104024 26259 130283 37664 100.02 100.03COMMUNITY HEALTH IMPROVEMENT 726228 172 726400 209999 100.03 100.04HUNTINGTON COLLEGE NURSE 29349 11023 40372 11671 100.04 100.05MISC CATERING 129965 18831 148796 43016 100.05 100.06NON-ALLOWED OFFICE SPACE 100.06 101 CROSS FOOT ADJUSTMENTS 101 102 NEGATIVE COST CENTER 102 103 TOTAL 28988300 872833 2559300 3452813 28988300 6500990 1990443 237301 103 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/29/2009 10:07 COST ALLOCATION - GENERAL SERVICE COSTS WORKSHEET B PART I HOUSE- DIETARY CAFETERIA NURSING CENTRAL PHARMACY MEDICAL COST CENTER DESCRIPTION KEEPING ADMINIS- SERVICES & RECORDS & SUBTOTAL TRATION SUPPLY LIBRARY 10 11 12 14 15 16 17 25 GENERAL SERVICE COST CENTERS 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 3 4 NEW CAP REL COSTS-MVBLE EQUIP 4 5 EMPLOYEE BENEFITS 5 6 ADMINISTRATIVE & GENERAL 6 7 MAINTENANCE & REPAIRS 7 8 OPERATION OF PLANT 8 9 LAUNDRY & LINEN SERVICE 9 10 HOUSEKEEPING 579807 10 11 DIETARY 37089 447783 11 12 CAFETERIA 8416 238751 12 13 MAINTENANCE OF PERSONNEL 13 14 NURSING ADMINISTRATION 2562 282405 14 15 CENTRAL SERVICES & SUPPLY 19371 2058 283508 15 16 PHARMACY 8757 7411 6631 734979 16 17 MEDICAL RECORDS & LIBRARY 4837 11260 832641 17 18 SOCIAL SERVICE 18 20 NONPHYSICIAN ANESTHETISTS 20 21 NURSING SCHOOL 21 22 I&R SERVICES-SALARY & FRINGES A 22 23 I&R SERVICES-OTHER PRGM COSTS A 23 24 PARAMED ED PRGM-(SPECIFY) 24 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 190754 447783 73551 175981 19007 95243 7471541 25 33 NURSERY 773 11843 20960 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 72663 23210 55536 19814 119082 3342447 37 41 RADIOLOGY-DIAGNOSTIC 91071 20324 9497 182143 2603081 41 44 LABORATORY 13799 85483 1921352 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 49 RESPIRATORY THERAPY 6262 14038 3558 23275 903074 49 50 PHYSICAL THERAPY 58182 14901 3073 24157 1562933 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO PAT 189784 56050 2102139 55 56 DRUGS CHARGED TO PATIENTS 10551 734979 80141 2450856 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 7011 4060 19741 538407 60 61 EMERGENCY 38818 21268 50888 5647 99447 2022515 61 62 OBSERVATION BEDS (NON-DISTINCT 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 26922 41157 11846 36036 2511663 65 71 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 PANCREAS ACQUISITION 85.01 85.02 INTESTINAL ACQUISITION 85.02 95 SUBTOTALS 577714 447783 238751 282405 283468 734979 832641 27450968 95 NONREIMBURSABLE COST CENTERS 96 GIFT, FLOWER, COFFEE SHOP & CAN 2093 11846 96 98 PHYSICIANS' PRIVATE OFFICES 6 98 100 OCC HEALTH 74106 100 100.01FOUNDATION 103133 100.01 100.02KIDS KAMPUS 1 167948 100.02 100.03COMMUNITY HEALTH IMPROVEMENT 39 936438 100.03 100.04HUNTINGTON COLLEGE NURSE 52043 100.04 100.05MISC CATERING 191812 100.05 100.06NON-ALLOWED OFFICE SPACE 100.06 101 CROSS FOOT ADJUSTMENTS 101 102 NEGATIVE COST CENTER 102 103 TOTAL 579807 447783 238751 282405 283508 734979 832641 28988300 103 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/29/2009 10:07 COST ALLOCATION - GENERAL SERVICE COSTS WORKSHEET B PART I I&R COST & COST CENTER DESCRIPTION POST STEP- TOTAL DOWN ADJS 26 27 GENERAL SERVICE COST CENTERS 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 3 4 NEW CAP REL COSTS-MVBLE EQUIP 4 5 EMPLOYEE BENEFITS 5 6 ADMINISTRATIVE & GENERAL 6 7 MAINTENANCE & REPAIRS 7 8 OPERATION OF PLANT 8 9 LAUNDRY & LINEN SERVICE 9 10 HOUSEKEEPING 10 11 DIETARY 11 12 CAFETERIA 12 13 MAINTENANCE OF PERSONNEL 13 14 NURSING ADMINISTRATION 14 15 CENTRAL SERVICES & SUPPLY 15 16 PHARMACY 16 17 MEDICAL RECORDS & LIBRARY 17 18 SOCIAL SERVICE 18 20 NONPHYSICIAN ANESTHETISTS 20 21 NURSING SCHOOL 21 22 I&R SERVICES-SALARY & FRINGES A 22 23 I&R SERVICES-OTHER PRGM COSTS A 23 24 PARAMED ED PRGM-(SPECIFY) 24 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 7471541 25 33 NURSERY 20960 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 3342447 37 41 RADIOLOGY-DIAGNOSTIC 2603081 41 44 LABORATORY 1921352 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 49 RESPIRATORY THERAPY 903074 49 50 PHYSICAL THERAPY 1562933 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO PAT 2102139 55 56 DRUGS CHARGED TO PATIENTS 2450856 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 538407 60 61 EMERGENCY 2022515 61 62 OBSERVATION BEDS (NON-DISTINCT 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 2511663 65 71 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 PANCREAS ACQUISITION 85.01 85.02 INTESTINAL ACQUISITION 85.02 95 SUBTOTALS 27450968 95 NONREIMBURSABLE COST CENTERS 96 GIFT, FLOWER, COFFEE SHOP & CAN 11846 96 98 PHYSICIANS' PRIVATE OFFICES 6 98 100 OCC HEALTH 74106 100 100.01FOUNDATION 103133 100.01 100.02KIDS KAMPUS 167948 100.02 100.03COMMUNITY HEALTH IMPROVEMENT 936438 100.03 100.04HUNTINGTON COLLEGE NURSE 52043 100.04 100.05MISC CATERING 191812 100.05 100.06NON-ALLOWED OFFICE SPACE 100.06 101 CROSS FOOT ADJUSTMENTS 101 102 NEGATIVE COST CENTER 102 103 TOTAL 28988300 103 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:07 ALLOCATION OF NEW CAPITAL RELATED COSTS WORKSHEET B PART III DIR ASSGND NEW CAP NEW CAP CAP REL EMPLOYEE ADMINIS- OPERATION LAUNDRY COST CENTER DESCRIPTION CAP-REL BLDGS & MOVABLE COST TO BENEFITS TRATIVE & OF PLANT & LINEN COSTS FIXTURES EQUIPMENT BE ALLOC GENERAL SERVICE 0 3 4 4A 5 6 8 9 GENERAL SERVICE COST CENTERS 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 3 4 NEW CAP REL COSTS-MVBLE EQUIP 4 5 EMPLOYEE BENEFITS 992 992 992 5 6 ADMINISTRATIVE & GENERAL 57744 605813 663557 237 663794 6 7 MAINTENANCE & REPAIRS 7 8 OPERATION OF PLANT 230594 104928 335522 22 45579 381123 8 9 LAUNDRY & LINEN SERVICE 4729 4729 1 5065 3089 12884 9 10 HOUSEKEEPING 3849 1270 5119 23 12619 2514 848 10 11 DIETARY 36777 21531 58308 7 6499 24022 78 11 12 CAFETERIA 8345 8345 10 4599 5451 55 12 13 MAINTENANCE OF PERSONNEL 13 14 NURSING ADMINISTRATION 13 6408 14 15 CENTRAL SERVICES & SUPPLY 19208 14767 33975 6 4400 12546 240 15 16 PHARMACY 8683 223873 232556 34 15630 5671 16 17 MEDICAL RECORDS & LIBRARY 4796 4796 23 18323 3133 17 18 SOCIAL SERVICE 18 20 NONPHYSICIAN ANESTHETISTS 20 21 NURSING SCHOOL 21 22 I&R SERVICES-SALARY & FRINGES A 22 23 I&R SERVICES-OTHER PRGM COSTS A 23 24 PARAMED ED PRGM-(SPECIFY) 24 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 189148 322869 512017 215 131312 123544 4839 25 33 NURSERY 767 767 23 501 257 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 72051 589640 661691 74 63581 47061 1617 37 41 RADIOLOGY-DIAGNOSTIC 90304 220554 310858 64 45183 58983 1024 41 44 LABORATORY 13682 13682 40655 8937 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 49 RESPIRATORY THERAPY 6210 59900 66110 35 19115 4056 49 50 PHYSICAL THERAPY 57692 35764 93456 52 28624 37682 859 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO PAT 42508 55 56 DRUGS CHARGED TO PATIENTS 37215 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 97557 97557 18 11432 454 60 61 EMERGENCY 38491 35505 73996 61 37466 25141 2117 61 62 OBSERVATION BEDS (NON-DISTINCT 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 26696 225329 252025 82 52565 17437 496 65 71 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 PANCREAS ACQUISITION 85.01 85.02 INTESTINAL ACQUISITION 85.02 95 SUBTOTALS 870758 2559300 3430058 977 628801 379768 12884 95 NONREIMBURSABLE COST CENTERS 96 GIFT, FLOWER, COFFEE SHOP & CAN 2075 2075 61 1355 96 98 PHYSICIANS' PRIVATE OFFICES 98 100 OCC HEALTH 1697 100 100.01FOUNDATION 2362 100.01 100.02KIDS KAMPUS 7 3846 100.02 100.03COMMUNITY HEALTH IMPROVEMENT 21443 100.03 100.04HUNTINGTON COLLEGE NURSE 3 1192 100.04 100.05MISC CATERING 5 4392 100.05 100.06NON-ALLOWED OFFICE SPACE 100.06 101 CROSS FOOT ADJUSTMENTS 101 102 NEGATIVE COST CENTER 102 103 TOTAL 872833 2559300 3432133 992 663794 381123 12884 103 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:07 ALLOCATION OF NEW CAPITAL RELATED COSTS WORKSHEET B PART III HOUSE- DIETARY CAFETERIA NURSING CENTRAL PHARMACY MEDICAL COST CENTER DESCRIPTION KEEPING ADMINIS- SERVICES & RECORDS & SUBTOTAL TRATION SUPPLY LIBRARY 10 11 12 14 15 16 17 25 GENERAL SERVICE COST CENTERS 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 3 4 NEW CAP REL COSTS-MVBLE EQUIP 4 5 EMPLOYEE BENEFITS 5 6 ADMINISTRATIVE & GENERAL 6 7 MAINTENANCE & REPAIRS 7 8 OPERATION OF PLANT 8 9 LAUNDRY & LINEN SERVICE 9 10 HOUSEKEEPING 21123 10 11 DIETARY 1351 90265 11 12 CAFETERIA 307 18767 12 13 MAINTENANCE OF PERSONNEL 13 14 NURSING ADMINISTRATION 201 6622 14 15 CENTRAL SERVICES & SUPPLY 706 162 52035 15 16 PHARMACY 319 583 1217 256010 16 17 MEDICAL RECORDS & LIBRARY 176 885 27336 17 18 SOCIAL SERVICE 18 20 NONPHYSICIAN ANESTHETISTS 20 21 NURSING SCHOOL 21 22 I&R SERVICES-SALARY & FRINGES A 22 23 I&R SERVICES-OTHER PRGM COSTS A 23 24 PARAMED ED PRGM-(SPECIFY) 24 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 6949 90265 5782 4127 3489 3123 885662 25 33 NURSERY 28 388 1964 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 2647 1824 1302 3637 3904 787338 37 41 RADIOLOGY-DIAGNOSTIC 3318 1598 1743 6010 428781 41 44 LABORATORY 503 2803 66580 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 49 RESPIRATORY THERAPY 228 1103 653 763 92063 49 50 PHYSICAL THERAPY 2120 1171 564 792 165320 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO PAT 34832 1838 79178 55 56 DRUGS CHARGED TO PATIENTS 1937 256010 2627 297789 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 551 745 647 111404 60 61 EMERGENCY 1414 1672 1193 1037 3260 147357 61 62 OBSERVATION BEDS (NON-DISTINCT 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 981 3235 2174 1181 330176 65 71 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 PANCREAS ACQUISITION 85.01 85.02 INTESTINAL ACQUISITION 85.02 95 SUBTOTALS 21047 90265 18767 6622 52028 256010 27336 3393612 95 NONREIMBURSABLE COST CENTERS 96 GIFT, FLOWER, COFFEE SHOP & CAN 76 3567 96 98 PHYSICIANS' PRIVATE OFFICES 98 100 OCC HEALTH 1697 100 100.01FOUNDATION 2362 100.01 100.02KIDS KAMPUS 3853 100.02 100.03COMMUNITY HEALTH IMPROVEMENT 7 21450 100.03 100.04HUNTINGTON COLLEGE NURSE 1195 100.04 100.05MISC CATERING 4397 100.05 100.06NON-ALLOWED OFFICE SPACE 100.06 101 CROSS FOOT ADJUSTMENTS 101 102 NEGATIVE COST CENTER 102 103 TOTAL 21123 90265 18767 6622 52035 256010 27336 3432133 103 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:07 ALLOCATION OF NEW CAPITAL RELATED COSTS WORKSHEET B PART III I&R COST & COST CENTER DESCRIPTION POST STEP- TOTAL DOWN ADJS 26 27 GENERAL SERVICE COST CENTERS 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 3 4 NEW CAP REL COSTS-MVBLE EQUIP 4 5 EMPLOYEE BENEFITS 5 6 ADMINISTRATIVE & GENERAL 6 7 MAINTENANCE & REPAIRS 7 8 OPERATION OF PLANT 8 9 LAUNDRY & LINEN SERVICE 9 10 HOUSEKEEPING 10 11 DIETARY 11 12 CAFETERIA 12 13 MAINTENANCE OF PERSONNEL 13 14 NURSING ADMINISTRATION 14 15 CENTRAL SERVICES & SUPPLY 15 16 PHARMACY 16 17 MEDICAL RECORDS & LIBRARY 17 18 SOCIAL SERVICE 18 20 NONPHYSICIAN ANESTHETISTS 20 21 NURSING SCHOOL 21 22 I&R SERVICES-SALARY & FRINGES A 22 23 I&R SERVICES-OTHER PRGM COSTS A 23 24 PARAMED ED PRGM-(SPECIFY) 24 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 885662 25 33 NURSERY 1964 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 787338 37 41 RADIOLOGY-DIAGNOSTIC 428781 41 44 LABORATORY 66580 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 49 RESPIRATORY THERAPY 92063 49 50 PHYSICAL THERAPY 165320 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO PAT 79178 55 56 DRUGS CHARGED TO PATIENTS 297789 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 111404 60 61 EMERGENCY 147357 61 62 OBSERVATION BEDS (NON-DISTINCT 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 330176 65 71 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 PANCREAS ACQUISITION 85.01 85.02 INTESTINAL ACQUISITION 85.02 95 SUBTOTALS 3393612 95 NONREIMBURSABLE COST CENTERS 96 GIFT, FLOWER, COFFEE SHOP & CAN 3567 96 98 PHYSICIANS' PRIVATE OFFICES 98 100 OCC HEALTH 1697 100 100.01FOUNDATION 2362 100.01 100.02KIDS KAMPUS 3853 100.02 100.03COMMUNITY HEALTH IMPROVEMENT 21450 100.03 100.04HUNTINGTON COLLEGE NURSE 1195 100.04 100.05MISC CATERING 4397 100.05 100.06NON-ALLOWED OFFICE SPACE 100.06 101 CROSS FOOT ADJUSTMENTS 101 102 NEGATIVE COST CENTER 102 103 TOTAL 3432133 103 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/29/2009 10:07 COST ALLOCATION - STATISTICAL BASIS WORKSHEET B-1 NEW CAP NEW CAP EMPLOYEE ADMINIS- OPERATION LAUNDRY COST CENTER DESCRIPTION BLDGS & MOVABLE BENEFITS RECON- TRATIVE & OF PLANT & LINEN FIXTURES EQUIPMENT CILIATION GENERAL SERVICE SQUARE DOLLAR GROSS ACCUM SQUARE POUNDS OF FEET VALUE SALARIES COST FEET LAUNDRY 3 4 5 6A 6 8 9 GENERAL SERVICE COST CENTERS 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 116102 3 4 NEW CAP REL COSTS-MVBLE EQUIP 906954 4 5 EMPLOYEE BENEFITS 132 13315819 5 6 ADMINISTRATIVE & GENERAL 7681 214686 3128861 -6500990 22487310 6 7 MAINTENANCE & REPAIRS 7 8 OPERATION OF PLANT 30673 37184 292618 1544061 77616 8 9 LAUNDRY & LINEN SERVICE 629 16953 171570 629 263366 9 10 HOUSEKEEPING 512 450 309088 427474 512 17338 10 11 DIETARY 4892 7630 88374 220162 4892 1587 11 12 CAFETERIA 1110 138136 155813 1110 1122 12 13 MAINTENANCE OF PERSONNEL 13 14 NURSING ADMINISTRATION 170810 217085 14 15 CENTRAL SERVICES & SUPPLY 2555 5233 77408 149042 2555 4914 15 16 PHARMACY 1155 79335 461561 529487 1155 16 17 MEDICAL RECORDS & LIBRARY 638 307104 620732 638 17 18 SOCIAL SERVICE 18 20 NONPHYSICIAN ANESTHETISTS 20 21 NURSING SCHOOL 21 22 I&R SERVICES-SALARY & FRINGES 22 23 I&R SERVICES-OTHER PRGM COSTS 23 24 PARAMED ED PRGM-(SPECIFY) 24 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 25160 114417 2899372 4448760 25160 98911 25 33 NURSERY 102 767 102 5259 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 9584 208954 994858 2153891 9584 33063 37 41 RADIOLOGY-DIAGNOSTIC 12012 78159 864884 1530633 12012 20941 41 44 LABORATORY 1820 1377242 1820 44 46.30 BLOOD CLOTTING FACTORS ADMIN 46.30 49 RESPIRATORY THERAPY 826 21227 467159 647553 826 49 50 PHYSICAL THERAPY 7674 12674 706257 969673 7674 17558 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO P 1440005 55 56 DRUGS CHARGED TO PATIENTS 1260717 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 34572 242279 387278 9274 60 61 EMERGENCY 5120 12582 829424 1269230 5120 43269 61 62 OBSERVATION BEDS (NON-DISTINC 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 3551 79851 1103610 1780713 3551 10130 65 71 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 PANCREAS ACQUISITION 85.01 85.02 INTESTINAL ACQUISITION 85.02 95 SUBTOTALS 115826 906954 13098756 -6500990 21301888 77340 263366 95 NONREIMBURSABLE COST CENTERS 96 GIFT, FLOWER, COFFEE SHOP & C 276 2075 276 96 98 PHYSICIANS' PRIVATE OFFICES 5 98 100 OCC HEALTH 57487 100 100.01 FOUNDATION 80004 100.01 100.02 KIDS KAMPUS 101269 130283 100.02 100.03 COMMUNITY HEALTH IMPROVEMENT 663 726400 100.03 100.04 HUNTINGTON COLLEGE NURSE 42511 40372 100.04 100.05 MISC CATERING 72620 148796 100.05 100.06 NON-ALLOWED OFFICE SPACE 100.06 101 CROSS FOOT ADJUSTMENTS 101 102 NEGATIVE COST CENTER 102 103 COST TO BE ALLOC PER B PT I 872833 2559300 3452813 6500990 1990443 237301 103 104 UNIT COST MULT-WS B PT I 2.821863 25.644751 104 104 UNIT COST MULT-WS B PT I 7.517812 .259302 .289096 .901031 104 105 COST TO BE ALLOC PER B PT II 105 106 UNIT COST MULT-WS B PT II 106 106 UNIT COST MULT-WS B PT II 106 107 COST TO BE ALLOC PER B PT III 992 663794 381123 12884 107 108 UNIT COST MULT-WS B PT III 4.910366 108 108 UNIT COST MULT-WS B PT III .000074 .029519 .048921 108 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/29/2009 10:07 COST ALLOCATION - STATISTICAL BASIS WORKSHEET B-1 HOUSE- DIETARY CAFETERIA NURSING CENTRAL PHARMACY MEDICAL COST CENTER DESCRIPTION KEEPING ADMINIS- SERVICES & RECORDS & TRATION SUPPLY LIBRARY SQUARE MEALS HOURS OF DIRECT COSTED COSTED GROSS FEET SERVED SERVICE NRSING HRS REQUIS. REQUIS. REVENUE 10 11 12 14 15 16 17 GENERAL SERVICE COST CENTERS 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 3 4 NEW CAP REL COSTS-MVBLE EQUIP 4 5 EMPLOYEE BENEFITS 5 6 ADMINISTRATIVE & GENERAL 6 7 MAINTENANCE & REPAIRS 7 8 OPERATION OF PLANT 8 9 LAUNDRY & LINEN SERVICE 9 10 HOUSEKEEPING 76475 10 11 DIETARY 4892 30761 11 12 CAFETERIA 1110 364661 12 13 MAINTENANCE OF PERSONNEL 13 14 NURSING ADMINISTRATION 3913 180271 14 15 CENTRAL SERVICES & SUPPLY 2555 3144 2153951 15 16 PHARMACY 1155 11320 50377 100 16 17 MEDICAL RECORDS & LIBRARY 638 17198 81979030 17 18 SOCIAL SERVICE 18 20 NONPHYSICIAN ANESTHETISTS 20 21 NURSING SCHOOL 21 22 I&R SERVICES-SALARY & FRINGES 22 23 I&R SERVICES-OTHER PRGM COSTS 23 24 PARAMED ED PRGM-(SPECIFY) 24 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 25160 30761 112336 112336 144407 9377098 25 33 NURSERY 102 1165995 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 9584 35451 35451 150540 11724115 37 41 RADIOLOGY-DIAGNOSTIC 12012 31043 72151 17934631 41 44 LABORATORY 1820 8416210 44 46.30 BLOOD CLOTTING FACTORS ADMIN 46.30 49 RESPIRATORY THERAPY 826 21441 27032 2291501 49 50 PHYSICAL THERAPY 7674 22760 23347 2378364 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO P 1441873 5518342 55 56 DRUGS CHARGED TO PATIENTS 80162 100 7890186 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 10709 30846 1943631 60 61 EMERGENCY 5120 32484 32484 42906 9791021 61 62 OBSERVATION BEDS (NON-DISTINC 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 3551 62862 90000 3547936 65 71 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 PANCREAS ACQUISITION 85.01 85.02 INTESTINAL ACQUISITION 85.02 95 SUBTOTALS 76199 30761 364661 180271 2153641 100 81979030 95 NONREIMBURSABLE COST CENTERS 96 GIFT, FLOWER, COFFEE SHOP & C 276 96 98 PHYSICIANS' PRIVATE OFFICES 98 100 OCC HEALTH 100 100.01 FOUNDATION 100.01 100.02 KIDS KAMPUS 10 100.02 100.03 COMMUNITY HEALTH IMPROVEMENT 300 100.03 100.04 HUNTINGTON COLLEGE NURSE 100.04 100.05 MISC CATERING 100.05 100.06 NON-ALLOWED OFFICE SPACE 100.06 101 CROSS FOOT ADJUSTMENTS 101 102 NEGATIVE COST CENTER 102 103 COST TO BE ALLOC PER B PT I 579807 447783 238751 282405 283508 734979 832641 103 104 UNIT COST MULT-WS B PT I 7.581654 .654720 .131622 .010157 104 104 UNIT COST MULT-WS B PT I 14.556841 1.566558 7349.790000 104 105 COST TO BE ALLOC PER B PT II 105 106 UNIT COST MULT-WS B PT II 106 106 UNIT COST MULT-WS B PT II 106 107 COST TO BE ALLOC PER B PT III 21123 90265 18767 6622 52035 256010 27336 107 108 UNIT COST MULT-WS B PT III .276208 .051464 .024158 .000333 108 108 UNIT COST MULT-WS B PT III 2.934397 .036734 2560.100000 108 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (5/1999) 05/29/2009 10:07 COMPUTATION OF RATIO OF COST TO CHARGES WORKSHEET C PART I TOTAL COST THERAPY COST CENTER DESCRIPTION (FROM WKST B, LIMIT TOTAL RCE TOTAL PART I, COL 27) ADJUSTMENT COSTS DISALLOWANCE COSTS 1 2 3 4 5 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 7471541 7471541 7471541 25 33 NURSERY 20960 20960 20960 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 3342447 3342447 15003 3357450 37 41 RADIOLOGY-DIAGNOSTIC 2603081 2603081 2603081 41 44 LABORATORY 1921352 1921352 1921352 44 46.30 BLOOD CLOTTING FACTORS ADMI 46.30 49 RESPIRATORY THERAPY 903074 903074 903074 49 50 PHYSICAL THERAPY 1562933 1562933 1562933 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO 2102139 2102139 2102139 55 56 DRUGS CHARGED TO PATIENTS 2450856 2450856 2450856 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 538407 538407 538407 60 61 EMERGENCY 2022515 2022515 2022515 61 62 OBSERVATION BEDS (NON-DISTI 2396860 2396860 2396860 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 2511663 2511663 2511663 65 101 SUBTOTAL 29847828 29847828 15003 29862831 101 102 LESS OBSERVATION BEDS 2396860 2396860 2396860 102 103 TOTAL 27450968 27450968 15003 27465971 103 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (5/1999) 05/29/2009 10:07 COMPUTATION OF RATIO OF COST TO CHARGES WORKSHEET C PART I (CONT) -------------- CHARGES --------------- COST TEFRA PPS COST CENTER DESCRIPTION OR OTHER INPATIENT INPATIENT INPATIENT OUTPATIENT TOTAL RATIO RATIO RATIO 6 7 8 9 10 11 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 7746931 7746931 25 33 NURSERY 1165995 1165995 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 3659730 8064385 11724115 .285092 .285092 .286371 37 41 RADIOLOGY-DIAGNOSTIC 1898997 16035634 17934631 .145143 .145143 .145143 41 44 LABORATORY 2240798 6175412 8416210 .228292 .228292 .228292 44 46.30 BLOOD CLOTTING FACTORS ADMI 46.30 49 RESPIRATORY THERAPY 1014396 1277105 2291501 .394097 .394097 .394097 49 50 PHYSICAL THERAPY 313956 2064408 2378364 .657146 .657146 .657146 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO 2920793 2597549 5518342 .380937 .380937 .380937 55 56 DRUGS CHARGED TO PATIENTS 3255274 4634912 7890186 .310621 .310621 .310621 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 336549 1607082 1943631 .277011 .277011 .277011 60 61 EMERGENCY 1272637 8518384 9791021 .206568 .206568 .206568 61 62 OBSERVATION BEDS (NON-DISTI 1630167 1630167 1.470316 1.470316 1.470316 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 3547936 3547936 .707922 .707922 .707922 65 101 SUBTOTAL 25826056 56152974 81979030 101 102 LESS OBSERVATION BEDS 102 103 TOTAL 25826056 56152974 81979030 103 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/29/2009 10:07 APPORTIONMENT OF INPATIENT ROUTINE SERVICE CAPITAL COSTS WORKSHEET D PART I CHECK [ ] TITLE V APPLICABLE [XX] TITLE XVIII-PT A BOXES [ ] TITLE XIX ---------- OLD CAPITAL ---------- ---------- NEW CAPITAL ---------- REDUCED REDUCED CAPITAL SWING-BED CAPITAL CAPITAL SWING-BED CAPITAL COST CENTER DESCRIPTION RELATED ADJUSTMENT RELATED RELATED ADJUSTMENT RELATED COST COST COST COST 1 2 3 4 5 6 INPAT ROUTINE SERV COST CTRS 25 ADULTS & PEDIATRICS 885662 885662 25 26 INTENSIVE CARE UNIT 26 27 CORONARY CARE UNIT 27 28 BURN INTENSIVE CARE UNIT 28 29 SURGICAL INTENSIVE CARE UNIT 29 30 OTHER SPECIAL CARE (SPECIFY) 30 31 SUBPROVIDER I 31 33 NURSERY 1964 1964 33 101 TOTAL 887626 887626 101 ---- OLD CAPITAL ---- ---- NEW CAPITAL ---- INPATIENT INPATIENT TOTAL INPATIENT PER PROGRAM PER PROGRAM COST CENTER DESCRIPTION PATIENT PROGRAM DIEM CAPITAL DIEM CAPITAL DAYS DAYS COST COST 7 8 9 10 11 12 INPAT ROUTINE SERV COST CTRS 25 ADULTS & PEDIATRICS 7899 2192 112.12 245767 25 26 INTENSIVE CARE UNIT 26 27 CORONARY CARE UNIT 27 28 BURN INTENSIVE CARE UNIT 28 29 SURGICAL INTENSIVE CARE UNIT 29 30 OTHER SPECIAL CARE (SPECIFY) 30 31 SUBPROVIDER I 31 33 NURSERY 895 2.19 33 101 TOTAL 8794 2192 245767 101 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:07 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE CAPITAL COSTS WORKSHEET D PART II CHECK [ ] TITLE V [XX] HOSPITAL (15-0091) [ ] SUB III [XX] PPS APPLICABLE [XX] TITLE XVIII-PT A [ ] SUB I [ ] SUB IV [ ] TEFRA BOXES [ ] TITLE XIX [ ] SUB II OLD NEW ---- OLD CAPITAL ---- ---- NEW CAPITAL ---- CAPITAL CAPITAL INPATIENT RATIO OF RATIO OF COST CENTER DESCRIPTION RELATED RELATED TOTAL PROGRAM COST TO CAPITAL COST TO CAPITAL COST COST CHARGES CHARGES CHARGES COSTS CHARGES COSTS 1 2 3 4 5 6 7 8 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 787338 11724115 857256 .067155 57569 37 41 RADIOLOGY-DIAGNOSTIC 428781 17934631 968509 .023908 23155 41 44 LABORATORY 66580 8416210 986883 .007911 7807 44 46.30 BLOOD CLOTTING FACTORS ADMIN 46.30 49 RESPIRATORY THERAPY 92063 2291501 506852 .040176 20363 49 50 PHYSICAL THERAPY 165320 2378364 .069510 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO P 79178 5518342 1268577 .014348 18202 55 56 DRUGS CHARGED TO PATIENTS 297789 7890186 1185637 .037742 44748 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 111404 1943631 227638 .057317 13048 60 61 EMERGENCY 147357 9791021 650310 .015050 9787 61 62 OBSERVATION BEDS (NON-DISTINC 284119 1630167 .174288 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 101 TOTAL 2459929 69518168 6651662 194679 101 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 APPORTIONMENT OF INPATIENT ROUTINE SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART III CHECK [ ] TITLE V APPLICABLE [XX] TITLE XVIII-PT A BOXES [ ] TITLE XIX INPATIENT NONPHYSICIAN MEDICAL SWING-BED TOTAL INPATIENT PROGRAM COST CENTER DESCRIPTION ANESTHETIST EDUCATION ADJUSTMENT TOTAL PATIENT PER PROGRAM PASS THRU COST COST AMOUNT COSTS DAYS DIEM DAYS COSTS 1 2 3 4 5 6 7 8 INPAT ROUTINE SERV COST CTRS 25 ADULTS & PEDIATRICS 7899 2192 25 26 INTENSIVE CARE UNIT 26 27 CORONARY CARE UNIT 27 28 BURN INTENSIVE CARE UNIT 28 29 SURGICAL INTENSIVE CARE UNIT 29 30 OTHER SPECIAL CARE (SPECIFY) 30 31 SUBPROVIDER I 31 33 NURSERY 895 33 34 SKILLED NURSING FACILITY 34 35 NURSING FACILITY 35 101 TOTAL 8794 2192 101 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:07 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV CHECK [ ] TITLE V [XX] HOSPITAL (15-0091) [ ] SUB IV [ ] PPS APPLICABLE [XX] TITLE XVIII-PT A [ ] SUB I [ ] SNF [ ] TEFRA BOXES [ ] TITLE XIX [ ] SUB II [ ] NF [ ] SUB III [ ] ICF/MR OUTPATIENT NONPHYSICIAN NONPHYSICIAN MEDICAL COST CENTER DESCRIPTION ANESTHETIST ANESTHETIST EDUCATION TOTAL COST COST COST N/A N/A N/A COSTS 1 1.01 2 2.01 2.02 2.03 3 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 37 41 RADIOLOGY-DIAGNOSTIC 41 44 LABORATORY 44 46.30 BLOOD CLOTTING FACTORS ADMIN 46.30 49 RESPIRATORY THERAPY 49 50 PHYSICAL THERAPY 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO P 55 56 DRUGS CHARGED TO PATIENTS 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 60 61 EMERGENCY 61 62 OBSERVATION BEDS (NON-DISTINC 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 101 TOTAL 101 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:07 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV CHECK [ ] TITLE V [XX] HOSPITAL (15-0091) [ ] SUB IV [ ] PPS APPLICABLE [XX] TITLE XVIII-PT A [ ] SUB I [ ] SNF [ ] TEFRA BOXES [ ] TITLE XIX [ ] SUB II [ ] NF [ ] SUB III [ ] ICF/MR INPATIENT OUTPATIENT RATIO OF OUTPATIENT INPATIENT PROGRAM OUTPATIENT COST CENTER DESCRIPTION PASS THROUGH TOTAL COST TO RATIO OF COST PROGRAM PASS THROUGH PROGRAM COSTS CHARGES CHARGES TO CHARGES CHARGES COSTS CHARGES 3.01 4 5 5.01 6 7 8 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 11724115 857256 1108812 37 41 RADIOLOGY-DIAGNOSTIC 17934631 968509 3528094 41 44 LABORATORY 8416210 986883 138981 44 46.30 BLOOD CLOTTING FACTORS ADMIN 46.30 49 RESPIRATORY THERAPY 2291501 506852 372585 49 50 PHYSICAL THERAPY 2378364 2771 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO P 5518342 1268577 452648 55 56 DRUGS CHARGED TO PATIENTS 7890186 1185637 1527473 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 1943631 227638 520684 60 61 EMERGENCY 9791021 650310 1661870 61 62 OBSERVATION BEDS (NON-DISTINC 1630167 282551 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 101 TOTAL 69518168 6651662 9596469 101 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:07 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV CHECK [ ] TITLE V [XX] HOSPITAL (15-0091) [ ] SUB IV [ ] PPS APPLICABLE [XX] TITLE XVIII-PT A [ ] SUB I [ ] SNF [ ] TEFRA BOXES [ ] TITLE XIX [ ] SUB II [ ] NF [ ] SUB III [ ] ICF/MR OUTPATIENT OUTPATIENT OUTPATIENT OUTPATIENT OUTPATIENT PROGRAM PROGRAM PROGRAM COST CENTER DESCRIPTION PROGRAM PROGRAM PASS THROUGH PASS THROUGH PASS THROUGH CHARGES CHARGES COSTS COSTS COSTS 8.01 8.02 9 9.01 9.02 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 37 41 RADIOLOGY-DIAGNOSTIC 41 44 LABORATORY 44 46.30 BLOOD CLOTTING FACTORS ADMIN 46.30 49 RESPIRATORY THERAPY 49 50 PHYSICAL THERAPY 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO P 55 56 DRUGS CHARGED TO PATIENTS 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 60 61 EMERGENCY 61 62 OBSERVATION BEDS (NON-DISTINC 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 101 TOTAL 101 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (8/2002) 05/29/2009 10:07 APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES AND VACCINE COST WORKSHEET D PARTS V & VI CHECK [ ] TITLE V - O/P [XX] HOSPITAL (15-0091) [ ] SNF APPLICABLE [XX] TITLE XVIII-PT B [ ] SUB I [ ] NF BOXES [ ] TITLE XIX - O/P [ ] SUB II [ ] S/B-SNF [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR --------- PROGRAM CHARGES ---------- OUTPATIENT COST TO CHARGE RATIO FROM WORKSHEET C, AMBULATORY OTHER COST CENTER DESCRIPTION PART II PART I PART II SURGICAL OUTPATIENT OUTPATIENT COL. 8 COL. 9 COL. 9 CENTER RADIOLOGY DIAGNOSTIC 1 1.01 1.02 2 3 4 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM .285092 .285092 .285092 37 41 RADIOLOGY-DIAGNOSTIC .145143 .145143 .145143 41 44 LABORATORY .228292 .228292 .228292 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 49 RESPIRATORY THERAPY .394097 .394097 .394097 49 50 PHYSICAL THERAPY .657146 .657146 .657146 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO PAT .380937 .380937 .380937 55 56 DRUGS CHARGED TO PATIENTS .310621 .310621 .310621 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC .277011 .277011 .277011 60 61 EMERGENCY .206568 .206568 .206568 61 62 OBSERVATION BEDS (NON-DISTINCT 1.470316 1.470316 1.470316 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES .707922 .707922 .707922 65 65.01 AMBULANCE CHARGES (S-2 LINE 56. .707922 .707922 65.01 65.02 AMBULANCE CHARGES (S-2 LINE 56. .707922 .707922 65.02 65.03 AMBULANCE CHARGES (S-2 LINE 56. .707922 .707922 65.03 101 SUBTOTAL 101 102 CRNA CHARGES 102 103 LESS PBP CLINIC LAB SERV-PGM ONLY CHRGS 103 104 NET CHARGES 104 PART VI - VACCINE COST APPORTIONMENT 1 1 DRUGS CHARGED TO PATIENTS - RATIO OF COST TO CHARGES .310621 1 2 PROGRAM VACCINE CHARGES 2 2.01 PROGRAM VACCINE CHARGES 2.01 3 PROGRAM COSTS 3 3.01 PROGRAM COSTS 3.01 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (8/2002) 05/29/2009 10:07 APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES AND VACCINE COST WORKSHEET D PARTS V & VI CHECK [ ] TITLE V - O/P [XX] HOSPITAL (15-0091) [ ] SNF APPLICABLE [XX] TITLE XVIII-PT B [ ] SUB I [ ] NF BOXES [ ] TITLE XIX - O/P [ ] SUB II [ ] S/B-SNF [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR ------------------ PROGRAM CHARGES ------------------- --------- PROGRAM COST --------- ALL PPS SER- PPS SER- PPS SER- OUTPATIENT OTHER (1) VICES ALL OTHER VICES VICES AMBULATORY OTHER COST CENTER DESCRIPTION (SEE (SEE (SEE (SEE (SEE SURGICAL OUTPATIENT OUTPATIENT INSTRU.) INSTRU.) INSTRU.) INSTRU.) INSTRU.) CENTER RADIOLOGY DIAGNOSTIC 5 5.01 5.02 5.03 5.04 6 7 8 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 1108812 37 41 RADIOLOGY-DIAGNOSTIC 3528094 41 44 LABORATORY 138981 44 46.30 BLOOD CLOTTING FACTORS ADMIN C 46.30 49 RESPIRATORY THERAPY 372585 49 50 PHYSICAL THERAPY 2771 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO PA 452648 55 56 DRUGS CHARGED TO PATIENTS 1527473 1893 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 520684 60 61 EMERGENCY 1661870 61 62 OBSERVATION BEDS (NON-DISTINCT 282551 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 65.01 AMBULANCE CHARGES (S-2 LINE 56 65.01 65.02 AMBULANCE CHARGES (S-2 LINE 56 65.02 65.03 AMBULANCE CHARGES (S-2 LINE 56 65.03 101 SUBTOTAL 9596469 1893 101 102 CRNA CHARGES 102 103 PBP CLINIC LAB 103 104 NET CHARGES 9596469 1893 104 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (8/2002) 05/29/2009 10:07 APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES AND VACCINE COST WORKSHEET D PARTS V & VI CHECK [ ] TITLE V - O/P [XX] HOSPITAL (15-0091) [ ] SNF APPLICABLE [XX] TITLE XVIII-PT B [ ] SUB I [ ] NF BOXES [ ] TITLE XIX - O/P [ ] SUB II [ ] S/B-SNF [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR -------------------- PROGRAM COST -------------------- HOSPITAL HOSPITAL PPS PPS PPS I/P PART B I/P PART B SERVICES ALL OTHER SERVICES SERVICES CHARGES COST COST CENTER DESCRIPTION ALL OTHER (COLUMNS (COLUMNS (COLUMNS (COLUMNS (SEE (COLUMNS (COLS 1x5) 1.01x5.01) 1.01x5.02) 1.01x5.03 1.01x5.04 INSTRU.) 1.02x10) 9 9.01 9.02 9.03 9.04 10 11 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 316113 37 41 RADIOLOGY-DIAGNOSTIC 512078 41 44 LABORATORY 31728 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 49 RESPIRATORY THERAPY 146835 49 50 PHYSICAL THERAPY 1821 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO PAT 172430 55 56 DRUGS CHARGED TO PATIENTS 474465 588 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 144235 60 61 EMERGENCY 343289 61 62 OBSERVATION BEDS (NON-DISTINCT 415439 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 65.01 AMBULANCE CHARGES (S-2 LINE 56. 65.01 65.02 AMBULANCE CHARGES (S-2 LINE 56. 65.02 65.03 AMBULANCE CHARGES (S-2 LINE 56. 65.03 101 SUBTOTAL 2558433 588 101 102 CRNA CHARGES 102 103 LESS PBP CLINIC LAB SERV-PGM ONLY CHRGS 103 104 NET CHARGES 2558433 588 104 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/29/2009 10:07 APPORTIONMENT OF INPATIENT ROUTINE SERVICE CAPITAL COSTS WORKSHEET D PART I CHECK [ ] TITLE V APPLICABLE [ ] TITLE XVIII-PT A BOXES [XX] TITLE XIX ---------- OLD CAPITAL ---------- ---------- NEW CAPITAL ---------- REDUCED REDUCED CAPITAL SWING-BED CAPITAL CAPITAL SWING-BED CAPITAL COST CENTER DESCRIPTION RELATED ADJUSTMENT RELATED RELATED ADJUSTMENT RELATED COST COST COST COST 1 2 3 4 5 6 INPAT ROUTINE SERV COST CTRS 25 ADULTS & PEDIATRICS 885662 885662 25 26 INTENSIVE CARE UNIT 26 27 CORONARY CARE UNIT 27 28 BURN INTENSIVE CARE UNIT 28 29 SURGICAL INTENSIVE CARE UNIT 29 30 OTHER SPECIAL CARE (SPECIFY) 30 31 SUBPROVIDER I 31 33 NURSERY 1964 1964 33 101 TOTAL 887626 887626 101 ---- OLD CAPITAL ---- ---- NEW CAPITAL ---- INPATIENT INPATIENT TOTAL INPATIENT PER PROGRAM PER PROGRAM COST CENTER DESCRIPTION PATIENT PROGRAM DIEM CAPITAL DIEM CAPITAL DAYS DAYS COST COST 7 8 9 10 11 12 INPAT ROUTINE SERV COST CTRS 25 ADULTS & PEDIATRICS 7899 291 112.12 32627 25 26 INTENSIVE CARE UNIT 26 27 CORONARY CARE UNIT 27 28 BURN INTENSIVE CARE UNIT 28 29 SURGICAL INTENSIVE CARE UNIT 29 30 OTHER SPECIAL CARE (SPECIFY) 30 31 SUBPROVIDER I 31 33 NURSERY 895 108 2.19 237 33 101 TOTAL 8794 399 32864 101 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:07 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE CAPITAL COSTS WORKSHEET D PART II CHECK [ ] TITLE V [XX] HOSPITAL (15-0091) [ ] SUB III [XX] PPS APPLICABLE [ ] TITLE XVIII-PT A [ ] SUB I [ ] SUB IV [ ] TEFRA BOXES [XX] TITLE XIX [ ] SUB II [ ] OTHER OLD NEW ---- OLD CAPITAL ---- ---- NEW CAPITAL ---- CAPITAL CAPITAL INPATIENT RATIO OF RATIO OF COST CENTER DESCRIPTION RELATED RELATED TOTAL PROGRAM COST TO CAPITAL COST TO CAPITAL COST COST CHARGES CHARGES CHARGES COSTS CHARGES COSTS 1 2 3 4 5 6 7 8 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 787338 11724115 167630 .067155 11257 37 41 RADIOLOGY-DIAGNOSTIC 428781 17934631 100655 .023908 2406 41 44 LABORATORY 66580 8416210 134215 .007911 1062 44 46.30 BLOOD CLOTTING FACTORS ADMIN 46.30 49 RESPIRATORY THERAPY 92063 2291501 67047 .040176 2694 49 50 PHYSICAL THERAPY 165320 2378364 7820 .069510 544 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO P 79178 5518342 29879 .014348 429 55 56 DRUGS CHARGED TO PATIENTS 297789 7890186 188076 .037742 7098 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 111404 1943631 18237 .057317 1045 60 61 EMERGENCY 147357 9791021 57134 .015050 860 61 62 OBSERVATION BEDS (NON-DISTINC 284119 1630167 .174288 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 101 TOTAL 2459929 69518168 770693 27395 101 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 APPORTIONMENT OF INPATIENT ROUTINE SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART III CHECK [ ] TITLE V APPLICABLE [ ] TITLE XVIII-PT A BOXES [XX] TITLE XIX INPATIENT NONPHYSICIAN MEDICAL SWING-BED TOTAL INPATIENT PROGRAM COST CENTER DESCRIPTION ANESTHETIST EDUCATION ADJUSTMENT TOTAL PATIENT PER PROGRAM PASS THRU COST COST AMOUNT COSTS DAYS DIEM DAYS COSTS 1 2 3 4 5 6 7 8 INPAT ROUTINE SERV COST CTRS 25 ADULTS & PEDIATRICS 7899 291 25 26 INTENSIVE CARE UNIT 26 27 CORONARY CARE UNIT 27 28 BURN INTENSIVE CARE UNIT 28 29 SURGICAL INTENSIVE CARE UNIT 29 30 OTHER SPECIAL CARE (SPECIFY) 30 31 SUBPROVIDER I 31 33 NURSERY 895 108 33 34 SKILLED NURSING FACILITY 34 35 NURSING FACILITY 35 101 TOTAL 8794 399 101 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:07 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV CHECK [ ] TITLE V [XX] HOSPITAL (15-0091) [ ] SUB IV [ ] PPS APPLICABLE [ ] TITLE XVIII-PT A [ ] SUB I [ ] SNF [ ] TEFRA BOXES [XX] TITLE XIX [ ] SUB II [ ] NF [ ] OTHER [ ] SUB III [ ] ICF/MR OUTPATIENT NONPHYSICIAN NONPHYSICIAN MEDICAL COST CENTER DESCRIPTION ANESTHETIST ANESTHETIST EDUCATION TOTAL COST COST COST N/A N/A N/A COSTS 1 1.01 2 2.01 2.02 2.03 3 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 37 41 RADIOLOGY-DIAGNOSTIC 41 44 LABORATORY 44 46.30 BLOOD CLOTTING FACTORS ADMIN 46.30 49 RESPIRATORY THERAPY 49 50 PHYSICAL THERAPY 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO P 55 56 DRUGS CHARGED TO PATIENTS 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 60 61 EMERGENCY 61 62 OBSERVATION BEDS (NON-DISTINC 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 101 TOTAL 101 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:07 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV CHECK [ ] TITLE V [XX] HOSPITAL (15-0091) [ ] SUB IV [ ] PPS APPLICABLE [ ] TITLE XVIII-PT A [ ] SUB I [ ] SNF [ ] TEFRA BOXES [XX] TITLE XIX [ ] SUB II [ ] NF [ ] OTHER [ ] SUB III [ ] ICF/MR INPATIENT OUTPATIENT RATIO OF OUTPATIENT INPATIENT PROGRAM OUTPATIENT COST CENTER DESCRIPTION PASS THROUGH TOTAL COST TO RATIO OF COST PROGRAM PASS THROUGH PROGRAM COSTS CHARGES CHARGES TO CHARGES CHARGES COSTS CHARGES 3.01 4 5 5.01 6 7 8 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 11724115 167630 37 41 RADIOLOGY-DIAGNOSTIC 17934631 100655 41 44 LABORATORY 8416210 134215 44 46.30 BLOOD CLOTTING FACTORS ADMIN 46.30 49 RESPIRATORY THERAPY 2291501 67047 49 50 PHYSICAL THERAPY 2378364 7820 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO P 5518342 29879 55 56 DRUGS CHARGED TO PATIENTS 7890186 188076 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 1943631 18237 60 61 EMERGENCY 9791021 57134 61 62 OBSERVATION BEDS (NON-DISTINC 1630167 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 101 TOTAL 69518168 770693 101 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:07 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV CHECK [ ] TITLE V [XX] HOSPITAL (15-0091) [ ] SUB IV [ ] PPS APPLICABLE [ ] TITLE XVIII-PT A [ ] SUB I [ ] SNF [ ] TEFRA BOXES [XX] TITLE XIX [ ] SUB II [ ] NF [ ] OTHER [ ] SUB III [ ] ICF/MR OUTPATIENT OUTPATIENT OUTPATIENT OUTPATIENT OUTPATIENT PROGRAM PROGRAM PROGRAM COST CENTER DESCRIPTION PROGRAM PROGRAM PASS THROUGH PASS THROUGH PASS THROUGH CHARGES CHARGES COSTS COSTS COSTS 8.01 8.02 9 9.01 9.02 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 37 41 RADIOLOGY-DIAGNOSTIC 41 44 LABORATORY 44 46.30 BLOOD CLOTTING FACTORS ADMIN 46.30 49 RESPIRATORY THERAPY 49 50 PHYSICAL THERAPY 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO P 55 56 DRUGS CHARGED TO PATIENTS 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 60 61 EMERGENCY 61 62 OBSERVATION BEDS (NON-DISTINC 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 101 TOTAL 101 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (8/2002) 05/29/2009 10:07 APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES AND VACCINE COST WORKSHEET D PARTS V & VI CHECK [ ] TITLE V - O/P [XX] HOSPITAL (15-0091) [ ] SNF APPLICABLE [ ] TITLE XVIII-PT B [ ] SUB I [ ] NF BOXES [XX] TITLE XIX - O/P [ ] SUB II [ ] S/B-SNF [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR --------- PROGRAM CHARGES ---------- OUTPATIENT COST TO CHARGE RATIO FROM WORKSHEET C, AMBULATORY OTHER COST CENTER DESCRIPTION PART II PART I PART II SURGICAL OUTPATIENT OUTPATIENT COL. 8 COL. 9 COL. 9 CENTER RADIOLOGY DIAGNOSTIC 1 1.01 1.02 2 3 4 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM .285092 .285092 .285092 37 41 RADIOLOGY-DIAGNOSTIC .145143 .145143 .145143 41 44 LABORATORY .228292 .228292 .228292 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 49 RESPIRATORY THERAPY .394097 .394097 .394097 49 50 PHYSICAL THERAPY .657146 .657146 .657146 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO PAT .380937 .380937 .380937 55 56 DRUGS CHARGED TO PATIENTS .310621 .310621 .310621 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC .277011 .277011 .277011 60 61 EMERGENCY .206568 .206568 .206568 61 62 OBSERVATION BEDS (NON-DISTINCT 1.470316 1.470316 1.470316 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES .707922 .707922 .707922 65 65.01 AMBULANCE CHARGES (S-2 LINE 56. .707922 .707922 65.01 65.02 AMBULANCE CHARGES (S-2 LINE 56. .707922 .707922 65.02 65.03 AMBULANCE CHARGES (S-2 LINE 56. .707922 .707922 65.03 101 SUBTOTAL 101 102 CRNA CHARGES 102 103 LESS PBP CLINIC LAB SERV-PGM ONLY CHRGS 103 104 NET CHARGES 104 PART VI - VACCINE COST APPORTIONMENT 1 1 DRUGS CHARGED TO PATIENTS - RATIO OF COST TO CHARGES .310621 1 2 PROGRAM VACCINE CHARGES 2 2.01 PROGRAM VACCINE CHARGES 2.01 3 PROGRAM COSTS 3 3.01 PROGRAM COSTS 3.01 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (8/2002) 05/29/2009 10:07 APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES AND VACCINE COST WORKSHEET D PARTS V & VI CHECK [ ] TITLE V - O/P [XX] HOSPITAL (15-0091) [ ] SNF APPLICABLE [ ] TITLE XVIII-PT B [ ] SUB I [ ] NF BOXES [XX] TITLE XIX - O/P [ ] SUB II [ ] S/B-SNF [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR ------------------ PROGRAM CHARGES ------------------- --------- PROGRAM COST --------- ALL PPS SER- PPS SER- PPS SER- OUTPATIENT OTHER (1) VICES ALL OTHER VICES VICES AMBULATORY OTHER COST CENTER DESCRIPTION (SEE (SEE (SEE (SEE (SEE SURGICAL OUTPATIENT OUTPATIENT INSTRU.) INSTRU.) INSTRU.) INSTRU.) INSTRU.) CENTER RADIOLOGY DIAGNOSTIC 5 5.01 5.02 5.03 5.04 6 7 8 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 290421 37 41 RADIOLOGY-DIAGNOSTIC 752764 41 44 LABORATORY 333076 44 46.30 BLOOD CLOTTING FACTORS ADMIN C 46.30 49 RESPIRATORY THERAPY 59856 49 50 PHYSICAL THERAPY 78436 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO PA 67582 55 56 DRUGS CHARGED TO PATIENTS 151988 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 59901 60 61 EMERGENCY 582023 61 62 OBSERVATION BEDS (NON-DISTINCT 123712 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 289093 65 65.01 AMBULANCE CHARGES (S-2 LINE 56 65.01 65.02 AMBULANCE CHARGES (S-2 LINE 56 65.02 65.03 AMBULANCE CHARGES (S-2 LINE 56 65.03 101 SUBTOTAL 2788852 101 102 CRNA CHARGES 102 103 PBP CLINIC LAB 103 104 NET CHARGES 2788852 104 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (8/2002) 05/29/2009 10:07 APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES AND VACCINE COST WORKSHEET D PARTS V & VI CHECK [ ] TITLE V - O/P [XX] HOSPITAL (15-0091) [ ] SNF APPLICABLE [ ] TITLE XVIII-PT B [ ] SUB I [ ] NF BOXES [XX] TITLE XIX - O/P [ ] SUB II [ ] S/B-SNF [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR -------------------- PROGRAM COST -------------------- HOSPITAL HOSPITAL PPS PPS PPS I/P PART B I/P PART B SERVICES ALL OTHER SERVICES SERVICES CHARGES COST COST CENTER DESCRIPTION ALL OTHER (COLUMNS (COLUMNS (COLUMNS (COLUMNS (SEE (COLUMNS (COLS 1x5) 1.01x5.01) 1.01x5.02) 1.01x5.03 1.01x5.04 INSTRU.) 1.02x10) 9 9.01 9.02 9.03 9.04 10 11 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 82797 37 41 RADIOLOGY-DIAGNOSTIC 109258 41 44 LABORATORY 76039 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 49 RESPIRATORY THERAPY 23589 49 50 PHYSICAL THERAPY 51544 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO PAT 25744 55 56 DRUGS CHARGED TO PATIENTS 47211 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 16593 60 61 EMERGENCY 120227 61 62 OBSERVATION BEDS (NON-DISTINCT 181896 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 204655 65 65.01 AMBULANCE CHARGES (S-2 LINE 56. 65.01 65.02 AMBULANCE CHARGES (S-2 LINE 56. 65.02 65.03 AMBULANCE CHARGES (S-2 LINE 56. 65.03 101 SUBTOTAL 939553 101 102 CRNA CHARGES 102 103 LESS PBP CLINIC LAB SERV-PGM ONLY CHRGS 103 104 NET CHARGES 939553 104 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART I [ ] TITLE V-INPT [XX] TITLE XVIII-PART A [ ] TITLE XIX-INPT PART I - ALL PROVIDER COMPONENTS HOSPITAL SUB I SUB II SUB III SUB IV SNF (PPS) (15-0091) INPATIENT DAYS 1 1 1 1 1 1 1 INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS AND SWING-BED DAYS 7899 1 EXCLUDING NEWBORN) 2 INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS, EXCLUDING SWING 7899 2 BED AND NEWBORN DAYS) 3 PRIVATE ROOM DAYS (EXCLUDING SWING-BED PRIVATE ROOM DAYS) 7899 3 4 SEMI-PRIVATE ROOM DAYS (EXCLUDING SWING-BED PRIVATE ROOM DAYS) 4 5 TOTAL SWING-BED SNF-TYPE INPATIENT DAYS (INCLUDING PRIVATE 5 ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 6 TOTAL SWING-BED SNF-TYPE INPATIENT DAYS (INCLUDING PRIVATE 6 ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 7 TOTAL SWING-BED NF-TYPE INPATIENT DAYS (INCL PRIVATE 7 ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 8 TOTAL SWING-BED NF-TYPE INPATIENT DAYS (INCL PRIVATE 8 ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 9 INPATIENT DAYS INCLUDING PRIVATE ROOM DAYS APPLICABLE TO THE 2192 9 PROGRAM (EXCLUDING SWING-BED AND NEWBORN DAYS) 10 SWING-BED SNF-TYPE INPATIENT DAYS APPLICABLE TO TITLE XVIII 10 ONLY (INCLUDING PRIVATE ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 11 SWING-BED SNF-TYPE INPATIENT DAYS APPLICABLE TO TITLE XVIII 11 ONLY (INCLUDING PRIVATE ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 12 SWING-BED NF-TYPE INPATIENT DAYS APPLICABLE TO TITLES V OR XIX 12 ONLY (INCLUDING PRIVATE ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 13 SWING-BED NF-TYPE INPATIENT DAYS APPLICABLE TO TITLES V OR XIX 13 ONLY (INCLUDING PRIVATE ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 14 MEDICALLY NECESSARY PRIVATE ROOM DAYS APPLICABLE TO THE 14 PROGRAM (EXCLUDING SWING-BED DAYS) 15 TOTAL NURSERY DAYS 15 16 TITLE V OR XIX NURSERY DAYS 16 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART I (CONT) [ ] TITLE V-INPT [XX] TITLE XVIII-PART A [ ] TITLE XIX-INPT PART I - ALL PROVIDER COMPONENTS HOSPITAL SUB I SUB II SUB III SUB IV SNF (PPS) (15-0091) SWING-BED ADJUSTMENT 1 1 1 1 1 1 17 MEDICARE RATE FOR SWING-BED SNF SERVICES APPLICABLE TO 17 SERVICES THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 18 MEDICARE RATE FOR SWING-BED SNF SERVICES APPLICABLE TO 18 SERVICES AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 19 MEDICAID RATE FOR SWING-BED NF SERVICES APPLICABLE TO 19 SERVICES THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 20 MEDICAID RATE FOR SWING-BED NF SERVICES APPLICABLE TO 20 SERVICES AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 21 TOTAL GENERAL INPATIENT ROUTINE SERVICE COST 7471541 21 22 SWING-BED COST APPLICABLE TO SNF-TYPE SERVICES THROUGH 22 DECEMBER 31 OF THE COST REPORTING PERIOD 23 SWING-BED COST APPLICABLE TO SNF-TYPE SERVICES AFTER 23 DECEMBER 31 OF THE COST REPORTING PERIOD 24 SWING-BED COST APPLICABLE TO NF-TYPE SERVICES THROUGH 24 DECEMBER 31 OF THE COST REPORTING PERIOD 25 SWING-BED COST APPLICABLE TO NF-TYPE SERVICES AFTER 25 DECEMBER 31 OF THE COST REPORTING PERIOD 26 TOTAL SWING-BED COST 26 27 GENERAL INPATIENT ROUTINE SERVICE COST NET OF SWING-BED COST 7471541 27 PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 GENERAL INPATIENT ROUTINE SERVICE CHARGES 28 (EXCLUDING SWING-BED CHARGES) 29 PRIVATE ROOM CHARGES (EXCLUDING SWING-BED CHARGES) 29 30 SEMI-PRIVATE ROOM CHARGES (EXCLUDING SWING-BED CHARGES) 30 31 GENERAL INPATIENT ROUTINE SERVICE COST/CHARGE RATIO 31 32 AVERAGE PRIVATE ROOM PER DIEM CHARGE 32 33 AVERAGE SEMI-PRIVATE ROOM PER DIEM CHARGE 33 34 AVERAGE PER DIEM PRIVATE ROOM CHARGE DIFFERENTIAL 34 35 AVERAGE PER DIEM PRIVATE ROOM COST DIFFERENTIAL 35 36 PRIVATE ROOM COST DIFFERENTIAL ADJUSTMENT 36 37 GENERAL INPATIENT ROUTINE SERVICE COST NET OF SWING-BED COST 7471541 37 AND PRIVATE ROOM COST DIFFERENTIAL PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART II [ ] TITLE V-INPT [XX] TITLE XVIII-PART A [ ] TITLE XIX-INPT PART II - HOSPITAL AND SUBPROVIDERS ONLY HOSPITAL SUB I SUB II SUB III SUB IV (PPS) (15-0091) PROGRAM INPATIENT OPERATING COST BEFORE 1 1 1 1 1 PASS THROUGH COST ADJUSTMENTS 38 ADJUSTED GENERAL INPATIENT ROUTINE SERVICE COST PER DIEM 945.88 38 39 PROGRAM GENERAL INPATIENT ROUTINE SERVICE COST 2073369 39 40 MEDICALLY NECESSARY PRIVATE ROOM COST APPLICABLE TO THE PROGRAM 40 41 TOTAL PROGRAM GENERAL INPATIENT ROUTINE SERVICE COST 2073369 41 TOTAL TOTAL AVERAGE PROGRAM PROGRAM I/P COST I/P DAYS PER DIEM DAYS COST 1 2 3 4 5 42 NURSERY (TITLES V AND XIX ONLY) 42 INTENSIVE CARE TYPE INPATIENT HOSPITAL UNITS 43 INTENSIVE CARE UNIT 43 44 CORONARY CARE UNIT 44 45 BURN INTENSIVE CARE UNIT 45 46 SURGICAL INTENSIVE CARE UNIT 46 47 OTHER SPECIAL CARE (SPECIFY) 47 HOSPITAL SUB I SUB II SUB III SUB IV (PPS) (15-0091) 1 1 1 1 1 48 PROGRAM INPATIENT ANCILLARY SERVICE COST 1860034 48 49 TOTAL PROGRAM INPATIENT COSTS 3933403 49 PASS THROUGH COST ADJUSTMENTS 50 PASS THROUGH COSTS APPLICABLE TO PROGRAM INPATIENT ROUTINE 245767 50 SERVICES 51 PASS THROUGH COSTS APPLICABLE TO PROGRAM INPATIENT 194679 51 ANCILLARY SERVICES 52 TOTAL PROGRAM EXCLUDABLE COST 440446 52 53 TOTAL PROGRAM INPATIENT OPERATING COST EXCLUDING CAPITAL 3492957 53 RELATED, NONPHYSICIAN ANESTHETIST AND MEDICAL EDUCATION COSTS PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART II (CONT) [ ] TITLE V-INPT [XX] TITLE XVIII-PART A [ ] TITLE XIX-INPT PART II - HOSPITAL AND SUBPROVIDERS ONLY HOSPITAL SUB I SUB II SUB III SUB IV (PPS) (15-0091) TARGET AMOUNT AND LIMITATION COMPUTATION 1 1 1 1 1 54 PROGRAM DISCHARGES 54 55 TARGET AMOUNT PER DISCHARGE 55 56 TARGET AMOUNT 56 57 DIFFERENCE BETWEEN ADJUSTED INPATIENT OPERATING COST AND 57 TARGET AMOUNT 58 BONUS PAYMENT 58 58.01 LESSER OF LINE 53/LINE 54 OR LINE 55 FROM THE COST REPORTING 58.01 PERIOD ENDING 1996, UPDATED & COMPOUNDED BY THE MARKET BASKET 58.02 LESSER OF LINE 53/LINE 54 OR LINE 55 FROM PRIOR YEAR COST 58.02 REPORT UPDATED BY THE MARKET BASKET 58.03 IF LINE 53/LINE 54 IS LESS THAN THE LOWER OF LINES 55, 58.01 58.03 OR 58.02, THE LESSER OF 50% OF THE AMOUNT BY WHICH OPERATING COSTS ARE LESS THAN EXPECTED COSTS, OR 1% OF THE TARGET AMOUNT 58.04 RELIEF PAYMENT 58.04 59 ALLOWABLE INPATIENT COST PLUS INCENTIVE PAYMENT 59 59.01 ALLOWABLE INPATIENT COST PER DISCHARGE (LTCH ONLY) 59.01 59.02 PROGRAM DISCHARGES PRIOR TO JULY 1 59.02 59.03 PROGRAM DISCHARGES AFTER JULY 1 59.03 59.04 PROGRAM DISCHARGES (SEE INSTRUCTIONS) 59.04 59.05 REDUCED INPAT COST PER DISCH. FOR DISCHARGES PRIOR TO JULY 1 59.05 59.06 REDUCED INPAT COST PER DISCHARGE FOR DISCHARGES AFTER JULY 1 59.06 59.07 REDUCED INPAT COST PER DISCHARGE (SEE INSTR.) (LTCH ONLY) 59.07 59.08 REDUCED INPATIENT COST PLUS INCENTIVE PAYMENT (SEE INSTR.) 59.08 PROGRAM INPATIENT ROUTINE SWING BED COST 60 MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS THROUGH 60 DECEMBER 31 OF THE COST REPORTING PERIOD 61 MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS AFTER 61 DECEMBER 31 OF THE COST REPORTING PERIOD 62 TOTAL MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS 62 63 TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS THROUGH 63 DECEMBER 31 OF THE COST REPORTING PERIOD 64 TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS AFTER 64 DECEMBER 31 OF THE COST REPORTING PERIOD 65 TOTAL TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS 65 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PARTS III & IV [ ] TITLE V-INPT [XX] TITLE XVIII-PART A [ ] TITLE XIX-INPT PART III - SKILLED NURSING FACILITY, NURSING FACILITY AND ICF/MR ONLY SNF 1 66 SNF/NF/ICF/MR ROUTINE SERVICE COST 66 67 ADJUSTED GENERAL INPATIENT ROUTINE SERVICE COST PER DIEM 67 68 PROGRAM ROUTINE SERVICE COST 68 69 MEDICALLY NECESSARY PRIVATE ROOM COST APPLICABLE TO PROGRAM 69 70 TOTAL PROGRAM GENERAL INPATIENT ROUTINE SERVICE COSTS 70 71 CAPITAL RELATED COST ALLOCATED TO INPATIENT ROUTINE SERV COSTS 71 72 PER DIEM CAPITAL RELATED COSTS 72 73 PROGRAM CAPITAL RELATED COSTS 73 74 INPATIENT ROUTINE SERVICE COST 74 75 AGGREGATE CHARGES TO BENEFICIARIES FOR EXCESS COSTS 75 76 TOTAL PGM ROUTINE SERVICE COSTS FOR COMPARISON TO COST LIMIT 76 77 INPATIENT ROUTINE SERVICE COST PER DIEM LIMITATION 77 78 INPATIENT ROUTINE SERVICE COST LIMITATION 78 79 REASONABLE INPATIENT ROUTINE SERVICE COSTS 79 80 PROGRAM INPATIENT ANCILLARY SERVICES 80 81 UTILIZATION REVIEW--PHYSICIAN COMPENSATION 81 82 TOTAL PROGRAM INPATIENT OPERATING COSTS 82 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PARTS III & IV [ ] TITLE V-INPT [XX] TITLE XVIII-PART A [ ] TITLE XIX-INPT HOSPITAL SUB I SUB II SUB III SUB IV (PPS) (15-0091) 1 1 1 1 1 PART IV - COMPUTATION OF OBSERVATION BED COST 83 TOTAL OBSERVATION BEDS 2534 83 84 ADJUSTED GENERAL INPATIENT ROUTINE COST PER DIEM 945.88 84 85 OBSERVATION BED COST 2396860 85 COMPUTATION OF OBSERVATION BED PASS THROUGH COST - HOSPITAL TOTAL ROUTINE COLUMN 1 OBSERVATION OBSERVATION BED COST DIVIDED BY BED COST PASS-THROUGH COST COST (FROM LINE 27) COLUMN 2 (FROM LINE 85) COL 3 TIMES COL 4 1 2 3 4 5 86 OLD CAPITAL-RELATED COST 7471541 2396860 86 87 NEW CAPITAL-RELATED COST 885662 7471541 .118538 2396860 284119 87 88 NON PHYSICIAN ANESTHETIST 7471541 2396860 88 89 MEDICAL EDUCATION 7471541 2396860 89 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART I [ ] TITLE V-INPT [ ] TITLE XVIII-PART A [XX] TITLE XIX-INPT PART I - ALL PROVIDER COMPONENTS HOSPITAL SUB I SUB II SUB III SUB IV NF (PPS) (15-0091) INPATIENT DAYS 1 1 1 1 1 1 1 INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS AND SWING-BED DAYS 7899 1 EXCLUDING NEWBORN) 2 INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS, EXCLUDING SWING 7899 2 BED AND NEWBORN DAYS) 3 PRIVATE ROOM DAYS (EXCLUDING SWING-BED PRIVATE ROOM DAYS) 7899 3 4 SEMI-PRIVATE ROOM DAYS (EXCLUDING SWING-BED PRIVATE ROOM DAYS) 4 5 TOTAL SWING-BED SNF-TYPE INPATIENT DAYS (INCLUDING PRIVATE 5 ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 6 TOTAL SWING-BED SNF-TYPE INPATIENT DAYS (INCLUDING PRIVATE 6 ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 7 TOTAL SWING-BED NF-TYPE INPATIENT DAYS (INCL PRIVATE 7 ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 8 TOTAL SWING-BED NF-TYPE INPATIENT DAYS (INCL PRIVATE 8 ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 9 INPATIENT DAYS INCLUDING PRIVATE ROOM DAYS APPLICABLE TO THE 291 9 PROGRAM (EXCLUDING SWING-BED AND NEWBORN DAYS) 10 SWING-BED SNF-TYPE INPATIENT DAYS APPLICABLE TO TITLE XVIII 10 ONLY (INCLUDING PRIVATE ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 11 SWING-BED SNF-TYPE INPATIENT DAYS APPLICABLE TO TITLE XVIII 11 ONLY (INCLUDING PRIVATE ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 12 SWING-BED NF-TYPE INPATIENT DAYS APPLICABLE TO TITLES V OR XIX 12 ONLY (INCLUDING PRIVATE ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 13 SWING-BED NF-TYPE INPATIENT DAYS APPLICABLE TO TITLES V OR XIX 13 ONLY (INCLUDING PRIVATE ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 14 MEDICALLY NECESSARY PRIVATE ROOM DAYS APPLICABLE TO THE 14 PROGRAM (EXCLUDING SWING-BED DAYS) 15 TOTAL NURSERY DAYS 895 15 16 TITLE V OR XIX NURSERY DAYS 108 16 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART I (CONT) [ ] TITLE V-INPT [ ] TITLE XVIII-PART A [XX] TITLE XIX-INPT PART I - ALL PROVIDER COMPONENTS HOSPITAL SUB I SUB II SUB III SUB IV NF (PPS) (15-0091) SWING-BED ADJUSTMENT 1 1 1 1 1 1 17 MEDICARE RATE FOR SWING-BED SNF SERVICES APPLICABLE TO 17 SERVICES THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 18 MEDICARE RATE FOR SWING-BED SNF SERVICES APPLICABLE TO 18 SERVICES AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 19 MEDICAID RATE FOR SWING-BED NF SERVICES APPLICABLE TO 19 SERVICES THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 20 MEDICAID RATE FOR SWING-BED NF SERVICES APPLICABLE TO 20 SERVICES AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 21 TOTAL GENERAL INPATIENT ROUTINE SERVICE COST 7471541 21 22 SWING-BED COST APPLICABLE TO SNF-TYPE SERVICES THROUGH 22 DECEMBER 31 OF THE COST REPORTING PERIOD 23 SWING-BED COST APPLICABLE TO SNF-TYPE SERVICES AFTER 23 DECEMBER 31 OF THE COST REPORTING PERIOD 24 SWING-BED COST APPLICABLE TO NF-TYPE SERVICES THROUGH 24 DECEMBER 31 OF THE COST REPORTING PERIOD 25 SWING-BED COST APPLICABLE TO NF-TYPE SERVICES AFTER 25 DECEMBER 31 OF THE COST REPORTING PERIOD 26 TOTAL SWING-BED COST 26 27 GENERAL INPATIENT ROUTINE SERVICE COST NET OF SWING-BED COST 7471541 27 PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 GENERAL INPATIENT ROUTINE SERVICE CHARGES 28 (EXCLUDING SWING-BED CHARGES) 29 PRIVATE ROOM CHARGES (EXCLUDING SWING-BED CHARGES) 29 30 SEMI-PRIVATE ROOM CHARGES (EXCLUDING SWING-BED CHARGES) 30 31 GENERAL INPATIENT ROUTINE SERVICE COST/CHARGE RATIO 31 32 AVERAGE PRIVATE ROOM PER DIEM CHARGE 32 33 AVERAGE SEMI-PRIVATE ROOM PER DIEM CHARGE 33 34 AVERAGE PER DIEM PRIVATE ROOM CHARGE DIFFERENTIAL 34 35 AVERAGE PER DIEM PRIVATE ROOM COST DIFFERENTIAL 35 36 PRIVATE ROOM COST DIFFERENTIAL ADJUSTMENT 36 37 GENERAL INPATIENT ROUTINE SERVICE COST NET OF SWING-BED COST 7471541 37 AND PRIVATE ROOM COST DIFFERENTIAL PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART II [ ] TITLE V-INPT [ ] TITLE XVIII-PART A [XX] TITLE XIX-INPT PART II - HOSPITAL AND SUBPROVIDERS ONLY HOSPITAL SUB I SUB II SUB III SUB IV (PPS) (15-0091) PROGRAM INPATIENT OPERATING COST BEFORE 1 1 1 1 1 PASS THROUGH COST ADJUSTMENTS 38 ADJUSTED GENERAL INPATIENT ROUTINE SERVICE COST PER DIEM 945.88 38 39 PROGRAM GENERAL INPATIENT ROUTINE SERVICE COST 275251 39 40 MEDICALLY NECESSARY PRIVATE ROOM COST APPLICABLE TO THE PROGRAM 40 41 TOTAL PROGRAM GENERAL INPATIENT ROUTINE SERVICE COST 275251 41 TOTAL TOTAL AVERAGE PROGRAM PROGRAM I/P COST I/P DAYS PER DIEM DAYS COST 1 2 3 4 5 42 NURSERY (TITLES V AND XIX ONLY) 20960 895 23.42 108 2529 42 INTENSIVE CARE TYPE INPATIENT HOSPITAL UNITS 43 INTENSIVE CARE UNIT 43 44 CORONARY CARE UNIT 44 45 BURN INTENSIVE CARE UNIT 45 46 SURGICAL INTENSIVE CARE UNIT 46 47 OTHER SPECIAL CARE (SPECIFY) 47 HOSPITAL SUB I SUB II SUB III SUB IV (PPS) (15-0091) 1 1 1 1 1 48 PROGRAM INPATIENT ANCILLARY SERVICE COST 211471 48 49 TOTAL PROGRAM INPATIENT COSTS 489251 49 PASS THROUGH COST ADJUSTMENTS 50 PASS THROUGH COSTS APPLICABLE TO PROGRAM INPATIENT ROUTINE 32864 50 SERVICES 51 PASS THROUGH COSTS APPLICABLE TO PROGRAM INPATIENT 27395 51 ANCILLARY SERVICES 52 TOTAL PROGRAM EXCLUDABLE COST 60259 52 53 TOTAL PROGRAM INPATIENT OPERATING COST EXCLUDING CAPITAL 428992 53 RELATED, NONPHYSICIAN ANESTHETIST AND MEDICAL EDUCATION COSTS PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART II (CONT) [ ] TITLE V-INPT [ ] TITLE XVIII-PART A [XX] TITLE XIX-INPT PART II - HOSPITAL AND SUBPROVIDERS ONLY HOSPITAL SUB I SUB II SUB III SUB IV (PPS) (15-0091) TARGET AMOUNT AND LIMITATION COMPUTATION 1 1 1 1 1 54 PROGRAM DISCHARGES 54 55 TARGET AMOUNT PER DISCHARGE 55 56 TARGET AMOUNT 56 57 DIFFERENCE BETWEEN ADJUSTED INPATIENT OPERATING COST AND 57 TARGET AMOUNT 58 BONUS PAYMENT 58 58.01 LESSER OF LINE 53/LINE 54 OR LINE 55 FROM THE COST REPORTING 58.01 PERIOD ENDING 1996, UPDATED & COMPOUNDED BY THE MARKET BASKET 58.02 LESSER OF LINE 53/LINE 54 OR LINE 55 FROM PRIOR YEAR COST 58.02 REPORT UPDATED BY THE MARKET BASKET 58.03 IF LINE 53/LINE 54 IS LESS THAN THE LOWER OF LINES 55, 58.01 58.03 OR 58.02, THE LESSER OF 50% OF THE AMOUNT BY WHICH OPERATING COSTS ARE LESS THAN EXPECTED COSTS, OR 1% OF THE TARGET AMOUNT 58.04 RELIEF PAYMENT 58.04 59 ALLOWABLE INPATIENT COST PLUS INCENTIVE PAYMENT 59 59.01 ALLOWABLE INPATIENT COST PER DISCHARGE (LTCH ONLY) 59.01 59.02 PROGRAM DISCHARGES PRIOR TO JULY 1 59.02 59.03 PROGRAM DISCHARGES AFTER JULY 1 59.03 59.04 PROGRAM DISCHARGES (SEE INSTRUCTIONS) 59.04 59.05 REDUCED INPAT COST PER DISCH. FOR DISCHARGES PRIOR TO JULY 1 59.05 59.06 REDUCED INPAT COST PER DISCHARGE FOR DISCHARGES AFTER JULY 1 59.06 59.07 REDUCED INPAT COST PER DISCHARGE (SEE INSTR.) (LTCH ONLY) 59.07 59.08 REDUCED INPATIENT COST PLUS INCENTIVE PAYMENT (SEE INSTR.) 59.08 PROGRAM INPATIENT ROUTINE SWING BED COST 60 MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS THROUGH 60 DECEMBER 31 OF THE COST REPORTING PERIOD 61 MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS AFTER 61 DECEMBER 31 OF THE COST REPORTING PERIOD 62 TOTAL MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS 62 63 TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS THROUGH 63 DECEMBER 31 OF THE COST REPORTING PERIOD 64 TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS AFTER 64 DECEMBER 31 OF THE COST REPORTING PERIOD 65 TOTAL TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS 65 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PARTS III & IV [ ] TITLE V-INPT [ ] TITLE XVIII-PART A [XX] TITLE XIX-INPT PART III - SKILLED NURSING FACILITY, NURSING FACILITY AND ICF/MR ONLY NF 1 66 SNF/NF/ICF/MR ROUTINE SERVICE COST 66 67 ADJUSTED GENERAL INPATIENT ROUTINE SERVICE COST PER DIEM 67 68 PROGRAM ROUTINE SERVICE COST 68 69 MEDICALLY NECESSARY PRIVATE ROOM COST APPLICABLE TO PROGRAM 69 70 TOTAL PROGRAM GENERAL INPATIENT ROUTINE SERVICE COSTS 70 71 CAPITAL RELATED COST ALLOCATED TO INPATIENT ROUTINE SERV COSTS 71 72 PER DIEM CAPITAL RELATED COSTS 72 73 PROGRAM CAPITAL RELATED COSTS 73 74 INPATIENT ROUTINE SERVICE COST 74 75 AGGREGATE CHARGES TO BENEFICIARIES FOR EXCESS COSTS 75 76 TOTAL PGM ROUTINE SERVICE COSTS FOR COMPARISON TO COST LIMIT 76 77 INPATIENT ROUTINE SERVICE COST PER DIEM LIMITATION 77 78 INPATIENT ROUTINE SERVICE COST LIMITATION 78 79 REASONABLE INPATIENT ROUTINE SERVICE COSTS 79 80 PROGRAM INPATIENT ANCILLARY SERVICES 80 81 UTILIZATION REVIEW--PHYSICIAN COMPENSATION 81 82 TOTAL PROGRAM INPATIENT OPERATING COSTS 82 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PARTS III & IV [ ] TITLE V-INPT [ ] TITLE XVIII-PART A [XX] TITLE XIX-INPT HOSPITAL SUB I SUB II SUB III SUB IV (PPS) (15-0091) 1 1 1 1 1 PART IV - COMPUTATION OF OBSERVATION BED COST 83 TOTAL OBSERVATION BEDS 2534 83 84 ADJUSTED GENERAL INPATIENT ROUTINE COST PER DIEM 945.88 84 85 OBSERVATION BED COST 2396860 85 COMPUTATION OF OBSERVATION BED PASS THROUGH COST - HOSPITAL TOTAL ROUTINE COLUMN 1 OBSERVATION OBSERVATION BED COST DIVIDED BY BED COST PASS-THROUGH COST COST (FROM LINE 27) COLUMN 2 (FROM LINE 85) COL 3 TIMES COL 4 1 2 3 4 5 86 OLD CAPITAL-RELATED COST 7471541 2396860 86 87 NEW CAPITAL-RELATED COST 885662 7471541 .118538 2396860 284119 87 88 NON PHYSICIAN ANESTHETIST 7471541 2396860 88 89 MEDICAL EDUCATION 7471541 2396860 89 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 INPATIENT ANCILLARY COST APPORTIONMENT WORKSHEET D-4 [ ] TITLE V [XX] HOSPITAL (15-0091) [ ] SNF [XX] PPS [XX] TITLE XVIII-PT A [ ] SUB I [ ] NF [ ] TEFRA [ ] TITLE XIX [ ] SUB II [ ] S/B-SNF [ ] OTHER [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR RATIO OF COST INPATIENT INPATIENT COST CENTER DESCRIPTION TO CHARGES PROGRAM CHARGES PROGRAM COSTS 1 2 3 INPATIENT ROUTINE SERVICE COST CENTERS 25 ADULTS & PEDIATRICS 2584802 25 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM .286371 857256 245493 37 41 RADIOLOGY-DIAGNOSTIC .145143 968509 140572 41 44 LABORATORY .228292 986883 225297 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 49 RESPIRATORY THERAPY .394097 506852 199749 49 50 PHYSICAL THERAPY .657146 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO PAT .380937 1268577 483248 55 56 DRUGS CHARGED TO PATIENTS .310621 1185637 368284 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC .277011 227638 63058 60 61 EMERGENCY .206568 650310 134333 61 62 OBSERVATION BEDS (NON-DISTINCT 1.470316 62 OTHER REIMBURSABLE COST CENTERS 63.50 RHC 63.50 63.60 FQHC 63.60 65 AMBULANCE SERVICES 65 101 TOTAL 6651662 1860034 101 102 LESS PBP CLINIC LAB SVCS-PGM ONLY CHARGES 102 103 NET CHARGES 6651662 103 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 INPATIENT ANCILLARY COST APPORTIONMENT WORKSHEET D-4 [ ] TITLE V [XX] HOSPITAL (15-0091) [ ] SNF [XX] PPS [ ] TITLE XVIII-PT A [ ] SUB I [ ] NF [ ] TEFRA [XX] TITLE XIX [ ] SUB II [ ] S/B-SNF [ ] OTHER [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR RATIO OF COST INPATIENT INPATIENT COST CENTER DESCRIPTION TO CHARGES PROGRAM CHARGES PROGRAM COSTS 1 2 3 INPATIENT ROUTINE SERVICE COST CENTERS 25 ADULTS & PEDIATRICS 516785 25 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM .286371 167630 48004 37 41 RADIOLOGY-DIAGNOSTIC .145143 100655 14609 41 44 LABORATORY .228292 134215 30640 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 49 RESPIRATORY THERAPY .394097 67047 26423 49 50 PHYSICAL THERAPY .657146 7820 5139 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO PAT .380937 29879 11382 55 56 DRUGS CHARGED TO PATIENTS .310621 188076 58420 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC .277011 18237 5052 60 61 EMERGENCY .206568 57134 11802 61 62 OBSERVATION BEDS (NON-DISTINCT 1.470316 62 OTHER REIMBURSABLE COST CENTERS 63.50 RHC 63.50 63.60 FQHC 63.60 65 AMBULANCE SERVICES 65 101 TOTAL 770693 211471 101 102 LESS PBP CLINIC LAB SVCS-PGM ONLY CHARGES 102 103 NET CHARGES 770693 103 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (05/2007) 05/29/2009 10:07 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART A PART A - INPATIENT HOSPITAL SERVICES UNDER PPS HOSPITAL SUB I SUB II SUB III SUB IV (15-0091) DRG AMOUNT 1 OTHER THAN OUTLIER PAYMENTS OCCURRING BEFORE OCTOBER 1 2374168 1 1.01 OTHER THAN OUTLIER PAYMENTS OCCURRING ON OR AFTER 791390 1.01 OCTOBER 1 AND BEFORE JANUARY 1 1.02 OTHER THAN OUTLIER PAYMENTS OCCURRING ON OR AFTER JAN 1 1.02 MANAGED CARE PATIENTS 1.03 PAYMENTS PRIOR TO MARCH 1 OR OCTOBER 1 1.03 1.04 PAYMENTS ON OR AFTER OCTOBER 1 AND PRIOR TO JANUARY 1 1.04 1.05 PAYMENTS ON OR AFTER JAN 1 BUT BEFORE APR 1/OCT 1 1.05 1.06 ADDITIONAL AMOUNT RECEIVED OR TO BE RECEIVED 1.06 1.07 PAYMENTS FOR DISCHARGES ON OR AFTER APRIL 1, 2001 1.07 THROUGH SEPTEMBER 30, 2001 1.08 SIMULATED PAYMENTS FROM THE PS&R ON OR AFTER 1.08 APRIL 1, 2001 THROUGH SEPTEMBER 30, 2001 2 OUTLIER PAYMENTS PRIOR TO OCTOBER 1, 1997 2 2.01 OUTLIER PAYMENTS ON OR AFTER OCTOBER 1, 1997 20599 2.01 INDIRECT MEDICAL EDUCATION ADJUSTMENT 3 BED DAYS AVAILABLE DIVIDED BY NO. OF DAYS IN CR PERIOD 29.13 3 3.01 NO OF INTERNS & RESIDENTS FROM WORKSHEET S-3, PART I 3.01 3.02 INDIRECT MEDICAL EDUCATION PERCENTAGE 3.02 3.03 INDIRECT MEDICAL EDUCATION ADJUSTMENT 3.03 3.04 FTE COUNT FOR ALLOPATHIC AND OSTEOPATHIC PGMS FOR THE 3.04 MOST RECENT CR PERIOD ENDING ON OR BEFORE DEC 31, 1996 3.05 FTE COUNT FOR ALLOPATHIC AND OSTEOPATHIC PGMS WHICH 3.05 MEET THE CRITERIA FOR AN ADD-ON TO THE CAP FOR NEW PROGRAMS IN ACCORDANCE WITH SECTION 1886(d)(5)(B)(viii) 3.06 ADJUSTED FTE COUNT FOR ALLOPATHIC AND OSTEOPATHIC PGMS 3.06 FOR AFFILIATED PROGRAMS IN ACCORDANCE WITH SECTION 1886(d)(5)(B)(viii) [ FOR CR PERIODS ENDING ] [ ON OR AFTER 7/1/2005 ] [E-3,PT.VI,LN.15][PLUS LN.3.06] 3.07 SUM OF LINES 3.04-3.06 0.00 0.00 3.07 3.08 FTE COUNT FOR ALLOPATHIC AND OSTEOPATHIC PROGRAMS IN 3.08 THE CURRENT YEAR FROM YOUR RECORDS 3.09 FOR CR PERIODS BEGINNING BEFORE OCTOBER 1, ENTER THE 3.09 PERCENTAGE OF DISCHARGES OCCURRING PRIOR TO OCTOBER 1 3.10 FOR CR PERIODS BEGINNING BEFORE OCTOBER 1, ENTER THE 3.10 PERCENTAGE OF DISCHARGES OCCURRING ON OR AFTER OCT. 1 3.11 FTE COUNT FOR THE PERIOD IDENTIFIED IN LINE 3.09 3.11 3.12 FTE COUNT FOR THE PERIOD IDENTIFIED IN LINE 3.10 3.12 3.13 FTE COUNT FOR RESIDENTS IN DENTAL & PODIATRIC PROGRAMS 3.13 3.14 CURRENT YEAR ALLOWABLE FTE 3.14 3.15 TOTAL ALLOWABLE FTE COUNT FOR THE PRIOR YEAR, IF NONE 3.15 BUT PRIOR YEAR TEACHING WAS IN EFFECT ENTER 1 HERE.. 3.16 TOTAL ALLOWABLE FTE COUNT FOR THE PENULTIMATE YEAR IF 3.16 THAT YEAR ENDED ON OR AFTER SEPTEMBER 30, 1997, OTHERWISE ENTER ZERO. IF THERE WAS NO FTE COUNT IN THIS PERIOD BUT PRIOR YR TEACHING WAS IN EFFECT ENTER 1 HERE.. RES. IN INIT YRS 3.17 SUM OF LINES 3.14 THROUGH 3.16 DIVIDED BY THE 0.00 3.17 NUMBER OF THOSE LINES IN EXCESS OF ZERO PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (05/2007) 05/29/2009 10:07 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART A PART A - INPATIENT HOSPITAL SERVICES UNDER PPS (CONT) HOSPITAL SUB I SUB II SUB III SUB IV (15-0091) 3.18 CURRENT YEAR RESIDENT TO BED RATIO 3.18 3.19 PRIOR YEAR RESIDENT TO BED RATIO 3.19 3.20 FOR COST REPORTING PERIODS BEGINNING ON OR AFTER 3.20 OCTOBER 1, 1997, ENTER THE LESSER OF LINES 3.18 OR 3.19 3.21 IME PAYMENTS FOR DSCHGS OCCURRING PRIOR TO OCTOBER 1 3.21 3.22 IME PAYMENTS FOR DSCHGS AFTER SEP 30 BUT BEFORE JAN 1 3.22 3.23 IME PAYMENTS FOR DSCHGS OCCURRING ON OR AFTER JANUARY 1 3.23 [SUM OF LINES][PLUS E-3,PT.VI] [ 3.21-3.23 ][ LINE 23 ] 3.24 SUM OF LINES 3.21-3.23 0 0 3.24 DISPROPORTIONATE SHARE ADJUSTMENT 4 PERCENTAGE OF SSI RECIPIENT PATIENT DAYS TO MEDICARE 0.0322 4 PART A PATIENT DAYS 4.01 PERCENTAGE OF MEDICAID PATIENT DAYS TO TOTAL DAYS 0.2545 4.01 4.02 SUM OF 4 AND 4.01 0.2867 4.02 4.03 ALLOWABLE DISPROPORTIONATE SHARE PERCENTAGE 0.1200 4.03 4.04 DISPROPORTIONATE SHARE ADJUSTMENT 379867 4.04 ADDITIONAL PAYMENT FOR HIGH PERCENTAGE OF ESRD BENEFICIARY DISCHARGES 5 TOTAL MEDICARE DISCHARGES ON WKST S-3, PART I EXCLUDING 5 DISCHARGES FOR DRGs 302, 316 AND 317 5.01 TOTAL ESRD MEDICARE DISCHARGES EXCLUDING DRGs 302, 5.01 316 AND 317 5.02 DIVIDE LINE 5.01 BY LINE 5 5.02 5.03 TOTAL MEDICARE ESRD INPATIENT DAYS EXCLUDING DRGs 5.03 302, 316 AND 317 5.04 RATIO OF AVERAGE LENGTH OF STAY TO ONE WEEK 5.04 5.05 AVERAGE WEEKLY COST FOR DIALYSIS TREATMENTS 5.05 5.06 TOTAL ADDITIONAL PAYMENT 5.06 6 SUBTOTAL 3566024 6 7 HOSPITAL SPECIFIC PAYMENTS 7 7.01 HOSPITAL SPECIFIC PAYMENTS (1996 HSR) 7.01 8 TOTAL PAYMENT FOR INPATIENT OPERATING COSTS 3566024 8 9 PAYMENT FOR INPATIENT PROGRAM CAPITAL 269423 9 10 EXCEPTION PAYMENT FOR INPATIENT PROGRAM CAPITAL 10 11 DIRECT GRADUATE MEDICAL EDUCATION PAYMENT 11 11.01 NURSING AND ALLIED HEALTH MANAGED CARE 11.01 11.02 ADD-ON PAYMENT FOR NEW TECHNOLOGIES 11.02 12 NET ORGAN ACQUISITION COST 12 13 COST OF TEACHING PHYSICIANS 13 14 ROUTINE SERVICE OTHER PASS THROUGH COSTS 14 15 ANCILLARY SERVICE OTHER PASS THROUGH COSTS 15 16 TOTAL 3835447 16 17 PRIMARY PAYER PAYMENTS 9685 17 18 TOTAL AMOUNT PAYABLE FOR PROGRAM BENEFICIARIES 3825762 18 19 DEDUCTIBLES BILLED TO PROGRAM BENEFICIARIES 451360 19 20 COINSURANCE BILLED TO PROGRAM BENEFICIARIES 10752 20 21 REIMBURSABLE BAD DEBTS 103816 21 21.01 REDUCED PROGRAM REIMBURSABLE BAD DEBTS 72671 21.01 21.02 REIMBURSABLE BAD DEBTS FOR DUAL ELIGIBLE BENEFICIARIES 65035 21.02 22 SUBTOTAL 3436321 22 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (05/2007) 05/29/2009 10:07 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART A PART A - INPATIENT HOSPITAL SERVICES UNDER PPS (CONT) HOSPITAL SUB I SUB II SUB III SUB IV (15-0091) 23 RECOVERY OF EXCESS DEPRECIATION RESULTING FROM PROVIDER 23 TERMINATION OR A DECREASE IN PROGRAM UTILIZATION 24 OTHER ADJUSTMENTS 24 25 AMOUNTS APPLICABLE TO PRIOR COST REPORTING PERIODS 25 RESULTING FROM DISPOSITION OF DEPRECIABLE ASSETS 26 AMOUNT DUE PROVIDER 3436321 26 27 SEQUESTRATION ADJUSTMENT 27 28 INTERIM PAYMENTS 3411482 28 28.01 TENTATIVE SETTLEMENT (FOR FI USE ONLY) 28.01 29 BALANCE DUE PROVIDER (PROGRAM) 24839 29 30 PROTESTED AMOUNTS (NONALLOWABLE COST REPORT ITEMS) 30 IN ACCORDANCE WITH CMS PUB 15-II, SECTION 115.2 TO BE COMPLETED BY INTERMEDIARY 50 OPERATING OUTLIER AMOUNT FROM WKST E, PART A, LINE 2.01 50 51 CAPITAL OUTLIER AMOUNT FROM WKST L, PART I, LINE 3.01 51 52 OPERATING OUTLIER RECONCILIATION AMOUNT (SEE INSTR.) 52 53 CAPITAL OUTLIER RECONILIATION AMOUNT (SEE INSTRUCTIONS) 53 54 THE RATE USED TO CALCULATE THE TIME VALUE OF MONEY 54 55 TIME VALUE OF MONEY (SEE INSTRUCTIONS) 55 56 CAPITAL TIME VALUE OF MONEY (SEE INSTRUCTIONS) 56 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:07 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART B PART B - MEDICAL AND OTHER HEALTH SERVICES HOSPITAL HOSPITAL HOSPITAL (15-0091) (15-0091) (15-0091) 1 1.01 1.02 1 MEDICAL AND OTHER SERVICES 588 1 1.01 MEDICAL AND OTHER SERVICES RENDERED ON OR 2558433 1.01 AFTER AUGUST 1, 2000 1.02 PPS PAYMENTS RECEIVED INCLUDING OUTLIERS 2044350 1.02 1.03 1996 HOSPITAL SPECIFIC PAYMENT TO COST 0.859 1.03 RATIO 1.04 LINE 1.01 TIMES LINE 1.03 2197694 1.04 1.05 LINE 1.02 DIVIDED BY LINE 1.04 93.02 1.05 1.06 TRANSITIONAL CORRIDOR PAYMENT 1.06 1.07 AMOUNT FROM WORKSHEET D, PART IV, 1.07 COLUMN 9, LINE 101 2 INTERNS AND RESIDENTS 2 3 ORGAN ACQUISITIONS 3 4 COST OF TEACHING PHYSICIANS 4 5 TOTAL COST 588 5 COMPUTATION OF LESSER OF COST OR CHARGES REASONABLE CHARGES 6 ANCILLARY SERVICE CHARGES 1893 6 7 INTERNS AND RESIDENTS SERVICE CHARGES 7 8 ORGAN ACQUISITION CHARGES 8 9 CHARGES OF PROFESSIONAL SERVICES OF 9 TEACHING PHYSICIANS 10 TOTAL REASONABLE CHARGES 1893 10 CUSTOMARY CHARGES 11 AGGREGATE AMOUNT ACTUALLY COLLECTED FROM 11 PATIENTS LIABLE FOR PAYMENT FOR SERVICES ON A CHARGE BASIS 12 AMOUNTS THAT WOULD HAVE BEEN REALIZED FROM 12 PATIENTS LIABLE FOR PAYMENT FOR SERVICES ON A CHARGE BASIS HAD SUCH PAYMENT BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(E) 13 RATIO OF LINE 11 TO LINE 12 13 14 TOTAL CUSTOMARY CHARGES 1893 14 15 EXCESS OF CUSTOMARY CHGES OVER REASONABLE 1305 15 COST 16 EXCESS OF REASONABLE COST OVER CUSTOMARY 16 CHARGES 17 LESSER OF COST OR CHARGES 588 17 17.01 TOTAL PPS PAYMENTS 2044350 17.01 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:07 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART B PART B - MEDICAL AND OTHER HEALTH SERVICES HOSPITAL HOSPITAL HOSPITAL (15-0091) (15-0091) (15-0091) 1 1.01 1.02 COMPUTATION OF REIMBURSEMENT SETTLEMENT 18 DEDUCTIBLES AND COINSURANCE 18 18.01 DEDUCTIBLES AND COINSURANCE RELATING TO 553497 18.01 LINE 17.01 19 SUBTOTAL 1491441 19 20 SUM OF AMOUNTS FROM WKST E, PARTS C,D & E 20 21 DIRECT GRADUATE MEDICAL EDUCATION PAYMENTS 21 22 ESRD DIRECT MEDICAL EDUCATION COSTS 22 23 SUBTOTAL 1491441 23 24 PRIMARY PAYER PAYMENTS 852 24 25 SUBTOTAL 1490589 25 REIMBURSABLE BAD DEBTS (EXCLUDE BAD DEBTS FOR PROFESSIONAL SERVICES) 26 COMPOSITE RATE ESRD 26 27 BAD DEBTS 134482 27 27.01 REDUCED REIMBURSABLE BAD DEBTS 94137 27.01 27.02 REIMBURSABLE BAD DEBTS FOR DUAL ELIGIBLE 84688 27.02 BENEFICIARIES (SEE INSTRUCTIONS) 28 SUBTOTAL 1584726 28 29 RECOVERY OF EXCESS DEPRECIATION RESULTING 29 FROM PROVIDER TERMINATION OR A DECREASE IN PROGRAM UTILIZATION 30 OTHER ADJUSTMENTS 30 30.99 OTHER ADJUSTMENTS (MSP-LCC RECONCILIATION 30.99 AMOUNT) 31 AMOUNTS APPLICABLE TO PRIOR COST REPORTING 31 PERIODS RESULTING FROM DISPOSITION OF DEPRECIABLE ASSETS 32 SUBTOTAL 1584726 32 33 SEQUESTRATION ADJUSTMENT 33 34 INTERIM PAYMENTS 1546281 34 34.01 TENTATIVE SETTLEMENT (FOR FI USE ONLY) 34.01 35 BALANCE DUE PROVIDER/PROGRAM 38445 35 36 PROTESTED AMOUNTS (NONALLOWABLE COST 36 REPORT ITEMS) IN ACCORDANCE WITH CMS PUB 15-II, SECTION 115.2 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART C PART C - OUTPATIENT AMBULATORY SURGICAL CENTER [ ] TITLE V [XX] TITLE XVIII [ ] TITLE XIX HOSPITAL (15-0091) OCTOBER 1, 1997 PRIOR TO ON OR AFTER 1 1.01 1 STANDARD OVERHEAD AMOUNTS (ASC FEES) 1 2 DEDUCTIBLES 2 3 SUBTOTAL 3 4 80 PERCENT OF LINE 3 4 5 ASC PORTION OF BLEND 5 6 OUTPATIENT ASC COST 6 COMPUTATION OF LESSER OF COST OR CHARGES 7 TOTAL CHARGES 7 CUSTOMARY CHARGES 8 AGGREGATE AMOUNT ACTUALLY COLLECTED FROM PATIENTS LIABLE FOR PAYMENT FOR SERVICES 8 ON A CHARGE BASIS 9 AMOUNTS THAT WOULD HAVE BEEN REALIZED FROM PATIENTS LIABLE FOR PAYMENT FOR SERVICES 9 ON A CHARGE BASIS HAD SUCH PAYMENT BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(E) 10 RATIO OF LINE 8 TO LINE 9 10 11 TOTAL CUSTOMARY CHARGES 11 12 EXCESS OF CUSTOMARY CHARGES OVER REASONABLE COST 12 13 EXCESS OF REASONABLE COST OVER CUSTOMARY CHARGES 13 14 LESSER OF COST OR CHARGES 14 COMPUTATION OF REIMBURSEMENT SETTLEMENT 15 DEDUCTIBLES AND COINSURANCE 15 16 TOTAL 16 17 HOSPITAL SPECIFIC PORTION OF BLEND 17 18 ASC BLENDED AMOUNT 18 19 LESSER OF LINES 16 OR 18 19 20 PART B DEDUCTIBLES AND COINSURANCE 20 21 ASC PAYMENT AMOUNT 21 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART D PART D - OUTPATIENT RADIOLOGY SERVICES [ ] TITLE V [XX] TITLE XVIII [ ] TITLE XIX HOSPITAL (15-0091) OCTOBER 1, 1997 PRIOR TO ON OR AFTER 1 1.01 1 PREVAILING CHARGES 1 2 62 PERCENT OF LINE 1 2 3 DEDUCTIBLES 3 4 SUBTOTAL 4 5 BLENDED CHARGE PROPORTION 5 6 COST OF OUTPATIENT RADIOLOGY 6 COMPUTATION OF LESSER OF COST OR CHARGES 7 TOTAL CHARGES 7 CUSTOMARY CHARGES 8 AGGREGATE AMOUNT ACTUALLY COLLECTED FROM PATIENTS LIABLE FOR PAYMENT FOR SERVICES 8 ON A CHARGE BASIS 9 AMOUNTS THAT WOULD HAVE BEEN REALIZED FROM PATIENTS LIABLE FOR PAYMENT FOR SERVICE 9 ON A CHARGE BASIS HAD SUCH PAYMENT BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(E) 10 RATIO OF LINE 8 TO LINE 9 10 11 TOTAL CUSTOMARY CHARGES 11 12 EXCESS OF CUSTOMARY CHARGES OVER REASONABLE COST 12 13 EXCESS OF REASONABLE COST OVER CUSTOMARY CHARGES 13 14 LESSER OF COST OR CHARGES 14 COMPUTATION OF REIMBURSEMENT SETTLEMENT 15 DEDUCTIBLES AND COINSURANCE 15 16 TOTAL 16 17 COST PROPORTION 17 18 OUTPATIENT RADIOLOGY BLENDED AMOUNT 18 19 LESSER OF LINE 16 OR LINE 18 19 20 PART B DEDUCTIBLES AND COINSURANCE 20 21 RADIOLOGY PAYMENT AMOUNT 21 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART E PART E - OTHER OUTPATIENT DIAGNOSTIC PROCEDURES [ ] TITLE V [XX] TITLE XVIII [ ] TITLE XIX HOSPITAL (15-0091) OCTOBER 1, 1997 PRIOR TO ON OR AFTER 1 1.01 1 PREVAILING CHARGES 1 2 42 PERCENT OF LINE 1 2 3 DEDUCTIBLES 3 4 SUBTOTAL 4 5 BLENDED CHARGE PROPORTION 5 6 COST OF OTHER OUTPATIENT DIAGNOSTIC PROCEDURES 6 COMPUTATION OF LESSER OF COST OR CHARGES 7 TOTAL CHARGES 7 CUSTOMARY CHARGES 8 AGGREGATE AMOUNT ACTUALLY COLLECTED FROM PATIENTS LIABLE FOR PAYMENT FOR SERVICES 8 ON A CHARGE BASIS 9 AMOUNTS THAT WOULD HAVE BEEN REALIZED FROM PATIENTS LIABLE FOR PAYMENT FOR SERVICE 9 ON A CHARGE BASIS HAD SUCH PAYMENT BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(E) 10 RATIO OF LINE 8 TO LINE 9 10 11 TOTAL CUSTOMARY CHARGES 11 12 EXCESS OF CUSTOMARY CHARGES OVER REASONABLE COST 12 13 EXCESS OF REASONABLE COST OVER CUSTOMARY CHARGES 13 14 LESSER OF COST OR CHARGES 14 COMPUTATION OF REIMBURSEMENT SETTLEMENT 15 DEDUCTIBLES AND COINSURANCE 15 16 TOTAL 16 17 COST PROPORTION 17 18 OTHER OUTPATIENT DIAGNOSTIC BLENDED AMOUNT 18 19 LESSER OF LINE 16 OR LINE 18 19 20 PART B DEDUCTIBLES AND COINSURANCE 20 21 DIAGNOSTIC PAYMENT AMOUNT 21 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:07 ANALYSIS OF PAYMENTS TO PROVIDERS FOR SERVICES RENDERED WORKSHEET E-1 HOSPITAL (15-0091) INPATIENT PART A PART B DESCRIPTION MM/DD/YYYY AMOUNT MM/DD/YYYY AMOUNT 1 2 3 4 1 TOTAL INTERIM PAYMENTS PAID TO PROVIDER 3428756 1519754 1 2 INTERIM PAYMENTS PAYABLE ON INDIVIDUAL BILLS EITHER NONE 32906 2 SUBMITTED OR TO BE SUBMITTED TO THE INTERMEDIARY FOR SERVICES RENDERED IN THE COST REPORTING PERIOD. IF NONE, WRITE 'NONE', OR ENTER A ZERO. 3 LIST SEPARATELY EACH RETROACTIVE LUMP SUM .01 3.01 ADJUSTMENT AMOUNT BASED ON SUBSEQUENT PROGRAM .02 3.02 REVISION OF THE INTERIM RATE FOR THE COST TO .03 NONE NONE 3.03 REPORTING PERIOD. ALSO SHOW DATE OF EACH PROVIDER .04 3.04 PAYMENT. IF NONE, WRITE 'NONE' OR ENTER A ZERO. .05 3.05 .50 07/28/2008 17274 07/28/2008 6379 3.50 PROVIDER .51 3.51 TO .52 3.52 PROGRAM .53 3.53 .54 3.54 SUBTOTAL .99 -17274 -6379 3.99 4 TOTAL INTERIM PAYMENTS 3411482 1546281 4 TO BE COMPLETED BY INTERMEDIARY 5 LIST SEPARATELY EACH TENTATIVE SETTLEMENT PAY- PROGRAM .01 5.01 MENT AFTER DESK REVIEW. ALSO SHOW DATE OF EACH TO .02 5.02 PAYMENT. IF NONE, WRITE 'NONE' OR ENTER A ZERO. PROVIDER .03 5.03 PROVIDER .50 5.50 TO .51 5.51 PROGRAM .52 5.52 SUBTOTAL .99 5.99 6 DETERMINED NET SETTLEMENT AMOUNT PROGRAM TO (BALANCE DUE) BASED ON THE COST PROVIDER .01 6.01 REPORT. PROVIDER TO .02 6.02 PROGRAM 7 TOTAL MEDICARE PROGRAM LIABILITY 7 NAME OF INTERMEDIARY: INTERMEDIARY NUMBER: _____________________________________________________ _____________ SIGNATURE OF AUTHORIZED PERSON: DATE (MO/DAY/YR): ___________________________________________ ________________ PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/1999) 05/29/2009 10:07 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E-3 PART III - TITLE V OR TITLE XIX SERVICES OR TITLE XVIII SNF PPS ONLY PART III [ ] TITLE V [ ] TITLE XVIII [XX] TITLE XIX HOSPITAL SUB I SUB II SUB III SUB IV NF I (15-0091) (PPS) COMPUTATION OF NET COST OF COVERED SERVICES 1 1 1 1 1 1 1 INPATIENT HOSPITAL/SNF/NF SERVICES 1 2 MEDICAL AND OTHER SERVICES 939553 2 3 INTERNS AND RESIDENTS 3 4 ORGAN ACQUISITION CERTIFIED TRANSPLANT CENTERS O 4 5 COST OF TEACHING PHYSICIANS 5 6 SUBTOTAL 939553 6 7 INPATIENT PRIMARY PAYER PAYMENTS 7 8 OUTPATIENT PRIMARY PAYER PAYMENTS 8 9 SUBTOTAL 939553 9 COMPUTATION OF LESSER OF COST OR CHARGES 10 ROUTINE SERVICE CHARGES 10 11 ANCILLARY SERVICE CHARGES 3559545 11 12 INTERNS AND RESIDENTS SERVICE CHARGES 12 13 ORGAN ACQUISITION CHARGES, NET OF REVENUE 13 14 TEACHING PHYSICIANS 14 15 INCENTIVE FROM TARGET AMOUNT COMPUTATION 15 16 TOTAL REASONABLE CHARGES 3559545 16 CUSTOMARY CHARGES 17 AMOUNT ACTUALLY COLLECTED FROM PATIENTS LIABLE 17 18 AMOUNTS THAT WOULD HAVE BEEN REALIZED FROM 18 A CHARGE BASIS HAD SUCH PAYMENT BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(E) 19 RATIO OF LINE 17 TO LINE 18 19 20 TOTAL CUSTOMARY CHARGES 3559545 20 21 EXCESS OF CUSTOMARY CHARGES OVER REASONABLE COST 2619992 21 22 EXCESS OF REASONABLE COST OVER CUSTOMARY CHARGES 22 23 COST OF COVERED SERVICES 939553 23 PROSPECTIVE PAYMENT AMOUNT 24 OTHER THAN OUTLIER PAYMENTS 24 25 OUTLIER PAYMENTS 25 26 PROGRAM CAPITAL PAYMENTS 26 27 CAPITAL EXCEPTION PAYMENTS 27 28 ROUTINE SERVICE OTHER PASS THROUGH COSTS 28 29 ANCILLARY SERVICE OTHER PASS THROUGH COSTS 29 30 SUBTOTAL 939553 30 31 CUSTOMARY CHARGES (TITLE XIX PPS COVERED 31 32 LESSER OF LINES 30 OR 31 32 33 DEDUCTIBLES (EXCLUDE PROFESSIONAL COMPONENT) 33 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/1999) 05/29/2009 10:07 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E-3 PART III - TITLE V OR TITLE XIX SERVICES OR TITLE XVIII SNF PPS ONLY PART III [ ] TITLE V [ ] TITLE XVIII [XX] TITLE XIX HOSPITAL SUB I SUB II SUB III SUB IV NF I (15-0091) (PPS) 1 1 1 1 1 1 COMPUTATION OF REIMBURSEMENT SETTLEMENT 34 EXCESS OF REASONABLE COST 34 35 SUBTOTAL 35 36 COINSURANCE 36 37 SUM OF AMOUNTS FROM WKST E, PARTS C,D AND E, 37 38 REIMBURSABLE BAD DEBTS 38 38.01 REDUCED REIMBURSABLE BAD DEBTS 38.01 38.02 REIMBURSABLE BAD DEBTS FOR DUAL ELIGIBLE 38.02 BENEFICIARIES (SEE INSTRUCTIONS) 39 UTILIZATION REVIEW 39 40 SUBTOTAL 40 41 INPATIENT ROUTINE SERVICE COST 41 42 MEDICARE INPATIENT ROUTINE CHARGES 42 43 AMOUNT ACTUALLY COLLECTED FROM PATIENTS LIABLE 43 44 AMOUNTS THAT WOULD HAVE BEEN REALIZED FROM 44 A CHARGE BASIS HAD SUCH PAYMENT BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(E) 45 RATIO OF LINE 43 TO LINE 44 45 46 TOTAL CUSTOMARY CHARGES 46 47 EXCESS OF CUSTOMARY CHARGES OVER REASONABLE COST 47 48 EXCESS OF REASONABLE COST OVER CUSTOMARY CHARGES 48 49 RECOVERY OF EXCESS DEPRECIATION RESULTING FROM 49 UTILIZATION 50 OTHER ADJUSTMENTS 50 51 AMOUNTS APPLICABLE TO PRIOR COST REPORTING 51 DEPRECIABLE ASSETS 52 SUBTOTAL 52 53 INDIRECT MEDICAL EDUCATION ADJUSTMENT 53 54 DIRECT GRADUATE MEDICAL EDUCATION PAYMENTS 54 55 TOTAL AMOUNT PAYABLE TO THE PROVIDER 55 56 SEQUESTRATION ADJUSTMENT 56 57 INTERIM PAYMENTS 57 57.01 TENTATIVE SETTLEMENT (FOR FI USE ONLY) 57.01 58 BALANCE DUE PROVIDER/PROGRAM 58 59 PROTESTED AMOUNTS (NONALLOWABLE COST REPORT 59 SECTION 115.2 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:07 BALANCE SHEET WORKSHEET G ASSETS GENERAL SPECIFIC ENDOWMENT PLANT FUND PURPOSE FUND FUND FUND 1 2 3 4 CURRENT ASSETS 1 CASH ON HAND AND IN BANKS -44016 1 2 TEMPORARY INVESTMENTS 2 3 NOTES RECEIVABLE 3 4 ACCOUNTS RECEIVABLE 5394788 4 5 OTHER RECEIVABLES 276552 5 6 ALLOWANCE FOR UNCOLLECTIBLE NOTES & ACCOUNTS RECEIVABLE 6 7 INVENTORY 248437 7 8 PREPAID EXPENSES 97022 8 9 OTHER CURRENT ASSETS 16033 9 10 DUE FROM OTHER FUNDS 10 11 TOTAL CURRENT ASSETS 5988816 11 FIXED ASSETS 12 LAND 12 12.01 ACCUMULATED DEPRECIATION 12.01 13 LAND IMPROVEMENTS 134980 13 13.01 ACCUMULATED DEPRECIATION -77252 13.01 14 BUILDINGS 1426564 14 14.01 ACCUMULATED DEPRECIATION -376691 14.01 15 LEASEHOLD IMPROVEMENTS 15 15.01 ACCUMULATED AMORTIZATION 15.01 16 FIXED EQUIPMENT 8428932 16 16.01 ACCUMULATED DEPRECIATION -6022986 16.01 17 AUTOMOBILES AND TRUCKS 17 17.01 ACCUMULATED DEPRECIATION 17.01 18 MAJOR MOVABLE EQUIPMENT 27222 18 18.01 ACCUMULATED DEPRECIATION 18.01 19 MINOR EQUIPMENT DEPRECIABLE 19 19.01 ACCUMULATED DEPRECIATION 19.01 20 MINOR EQUIPMENT-NONDEPRECIABLE 20 21 TOTAL FIXED ASSETS 3540769 21 OTHER ASSETS 22 INVESTMENTS 336179 22 23 DEPOSITS ON LEASES 23 24 DUE FROM OWNERS/OFFICERS 24 25 OTHER ASSETS 32486968 25 26 TOTAL OTHER ASSETS 32823147 26 27 TOTAL ASSETS 42352732 27 LIABILITIES AND FUND BALANCES GENERAL SPECIFIC ENDOWMENT PLANT FUND PURPOSE FUND FUND FUND 1 2 3 4 CURRENT LIABILITIES 28 ACCOUNTS PAYABLE 362633 28 29 SALARIES, WAGES & FEES PAYABLE 682273 29 30 PAYROLL TAXES PAYABLE 30 31 NOTES & LOANS PAYABLE (SHORT TERM) 8889 31 32 DEFERRED INCOME 32 33 ACCELERATED PAYMENTS 33 34 DUE TO OTHER FUNDS 34 35 OTHER CURRENT LIABILITIES 801847 35 36 TOTAL CURRENT LIABILITIES 1855642 36 LONG-TERM LIABILITIES 37 MORTGAGE PAYABLE 37 38 NOTES PAYABLE 19564 38 39 UNSECURED LOANS 39 40 LOANS FROM OWNERS .01 PRIOR TO 7/1/66 40 .02 ON OR AFTER 7/1/66 41 OTHER LONG TERM LIABILITIES 38095 41 42 TOTAL LONG TERM LIABILITIES 57659 42 43 TOTAL LIABILITIES 1913301 43 CAPITAL ACCOUNTS 44 GENERAL FUND BALANCE 40439431 44 45 SPECIFIC PURPOSE FUND BALANCE 45 46 DONOR CREATED-ENDOWMENT FUND BAL-RESTRICTED 46 47 DONOR CREATED-ENDOWMENT FUND BAL-UNRESTRICTED 47 48 GOVERNING BODY CREATED - ENDOWMENT FUND BAL 48 49 PLANT FUND BALANCE - INVESTED IN PLANT 49 50 PLANT FUND BALANCE - RESERVE FOR PLANT 50 IMPROVEMENT, REPLACEMENT AND EXPANSION 51 TOTAL FUND BALANCES 40439431 51 52 TOTAL LIABILITIES AND FUND BALANCES 42352732 52 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:07 STATEMENT OF CHANGES IN FUND BALANCES WORKSHEET G-1 GENERAL FUND SPECIFIC PURPOSE FUND ENDOWMENT FUND PLANT FUND 1 2 3 4 1 FUND BALANCES AT BEGINNING OF PERIOD 29108426 1 2 NET INCOME (LOSS) 11331005 2 3 TOTAL 40439431 3 4 ADDITIONS (CREDIT ADJUSTMENTS) 4 5 PTO PAYABLE 5 6 CAPITAL CONTRIBUTION 6 7 7 8 8 9 9 10 TOTAL ADDITIONS 10 11 SUBTOTAL 40439431 11 12 DEDUCTIONS (DEBIT ADJUSTMENTS) 12 13 ASSET TRANSFERS 13 14 14 15 15 16 16 17 17 18 TOTAL DEDUCTIONS 18 19 FUND BALANCE AT END OF PERIOD 40439431 19 PER BALANCE SHEET PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:07 STATEMENT OF PATIENT REVENUES AND OPERATING EXPENSES WORKSHEET G-2 PARTS I & II PART I - PATIENT REVENUES REVENUE CENTER INPATIENT OUTPATIENT TOTAL 1 2 3 GENERAL INPATIENT ROUTINE CARE SERVICES 1 HOSPITAL 6708730 6708730 1 2 SUBPROVIDER I 2 4 SWING BED - SNF 4 5 SWING BED - NF 5 6 SKILLED NURSING FACILITY 6 7 NURSING FACILITY 7 8 OTHER LONG TERM CARE 8 9 TOTAL GENERAL INPATIENT CARE SERVICES 6708730 6708730 9 INTENSIVE CARE TYPE INPATIENT HOSPITAL SERVICES 10 INTENSIVE CARE UNIT 10 11 CORONARY CARE UNIT 11 12 BURN INTENSIVE CARE UNIT 12 13 SURGICAL INTENSIVE CARE UNIT 13 14 OTHER SPECIAL CARE (SPECIFY) 14 15 TOTAL INTENSIVE CARE TYPE INPATIENT HOSPITAL SERVICE 15 16 TOTAL INPATIENT ROUTINE CARE SERVICES 6708730 6708730 16 17 ANCILLARY SERVICES 18693258 18693258 17 18 OUTPATIENT SERVICES 54620738 54620738 18 18.50 RHC 18.50 18.60 FQHC 18.60 19 HOME HEALTH AGENCY 19 20 AMBULANCE 3559520 3559520 20 21 CORF 21 22 ASC 22 23 HOSPICE 23 24 24 25 TOTAL PATIENT REVENUES 25401988 58180258 83582246 25 PART II - OPERATING EXPENSES 1 2 26 OPERATING EXPENSES 32924562 26 27 PROVISION FOR BAD DEBT 3917357 27 28 28 29 29 30 30 31 31 32 32 33 TOTAL ADDITIONS 3917357 33 34 DEDUCT (SPECIFY) 34 35 35 36 36 37 37 38 38 39 TOTAL DEDUCTIONS 39 40 TOTAL OPERATING EXPENSES 36841919 40 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:07 STATEMENT OF REVENUES AND EXPENSES WORKSHEET G-3 DESCRIPTION 1 TOTAL PATIENT REVENUES 83582246 1 2 LESS - CONTRACTUAL ALLOWANCES AND DISCOUNTS ON PATIENTS' ACCOUNTS 38202600 2 3 NET PATIENT REVENUES 45379646 3 4 LESS - TOTAL OPERATING EXPENSES 36841919 4 5 NET INCOME FROM SERVICE TO PATIENTS 8537727 5 6 CONTRIBUTIONS, DONATIONS, BEQUESTS, ETC. 6 7 INCOME FROM INVESTMENTS 1625324 7 8 REVENUE FROM TELEPHONE AND TELEGRAPH SERVICE 8 9 REVENUE FROM TELEVISION AND RADIO SERVICE 9 10 PURCHASE DISCOUNTS 10 11 REBATES AND REFUNDS OF EXPENSES 11 12 PARKING LOT RECEIPTS 12 13 REVENUE FROM LAUNDRY AND LINEN SERVICE 13 14 REVENUE FROM MEALS SOLD TO EMPLOYEES AND GUESTS 160022 14 15 REVENUE FROM RENTAL OF LIVING QUARTERS 15 16 REV FROM SALE OF MED & SURG SUPP TO OTHER THAN PATIENTS 16 17 REVENUE FROM SALE OF DRUGS TO OTHER THAN PATIENTS 331623 17 18 REVENUE FROM SALE OF MEDICAL RECORDS AND ABSTRACTS 18 19 TUITION (FEES, SALE OF TEXTBOOKS, UNIFORMS, ETC.) 33680 19 20 REVENUE FROM GIFTS, FLOWER, COFFEE SHOPS, CANTEEN 20 21 RENTAL OF VENDING MACHINES 21 22 RENTAL OF HOSPITAL SPACE 22 23 GOVERNMENTAL APPROPRIATIONS 23 24 PHYSICIAN OFFICE RENT 187797 24 24.01 GAIN (LOSS) SALE OF CAPITAL ASSETS 24.01 24.02 EMS SUBSIDY 251146 24.02 24.03 FILM AND SILVER SALES 137 24.03 24.04 MISCELLANEOUS REVENUE 203549 24.04 24.05 EXTRAORDINARY ITEM 24.05 25 TOTAL OTHER INCOME 2793278 25 26 TOTAL 11331005 26 27 27 28 28 29 29 30 TOTAL OTHER EXPENSES 30 31 NET INCOME (OR LOSS) FOR THE PERIOD 11331005 31 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/29/2009 10:07 CALCULATION OF CAPITAL PAYMENT - TITLE XVIII - FULLY PROSPECTIVE METHOD WORKSHEET L HOSPITAL HOSPITAL SUB I SUB II SUB III (15-0091) (15-0091) 1 1.01 PART I - FULLY PROSPECTIVE METHOD 1 CAPITAL HOSPITAL SPECIFIC RATE PAYMENTS 1 CAPITAL FEDERAL AMOUNT 2 CAPITAL DRG OTHER THAN OUTLIER 265952 2 3 CAPITAL DRG OUTLIER PAYMENTS FOR SERVICES RENDERED 3 PRIOR TO OCTOBER 1, 1997 3.01 CAPITAL DRG OUTLIER PAYMENTS FOR SERVICES RENDERED 3471 3.01 ON OR AFTER OCTOBER 1, 1997 INDIRECT MEDICAL EDUCATION ADJUSTMENT 4 TOTAL INPAT DAYS DIVIDED BY NO OF DAYS IN CR PERIOD 4 [ E-3,PT VI,LN.18] [E,PT A,LN.3.17][x E-3,PT VI,LN.1] 4.01 NO. OF INTERNS & RESIDENTS 0.00 0.00 4.01 4.02 INDIRECT MEDICAL EDUCATION PERCENTAGE 4.02 4.03 INDIRECT MEDICAL EDUCATON ADJUSTMENT 4.03 DISPROPORTIONATE SHARE ADJUSTMENT 5 % OF SSI RECIPIENT PAT DAYS TO MEDICARE PART A PAT DAYS 5 5.01 % OF MEDICAID PAT DAYS TO TOTAL DAYS ON WKST S-3, PART I 5.01 5.02 SUM OF LINES 5 AND 5.01 5.02 5.03 ALLOWABLE DISPROPORTIONATE SHARE PERCENTAGE 5.03 5.04 DISPROPORTIONATE SHARE ADJUSTMENT 5.04 6 TOTAL PROSPECTIVE CAPITAL PAYMENTS 269423 6 PART II - HOLD HARMLESS METHOD 1 NEW CAPITAL 1 2 OLD CAPITAL 2 3 TOTAL CAPITAL 3 4 RATIO OF NEW CAPITAL TO TOTAL CAPITAL 4 5 TOTAL CAPITAL PAYMENTS UNDER 100% FEDERAL RATE 5 6 REDUCTION FACTOR FOR HOLD HARMLESS PAYMENT 6 7 REDUCED OLD CAPITAL AMOUNT 7 8 HOLD HARMLESS PAYMENT FOR NEW CAPITAL 8 9 SUBTOTAL 9 10 PAYMENT UNDER HOLD HARMLESS (GREATER OF LINE 5 OR LINE 9) 10 PART III - PAYMENT UNDER REASONABLE COST 1 PROGRAM INPATIENT ROUTINE CAPITAL COST 1 2 PROGRAM INPATIENT ANCILLARY CAPITAL COST 2 3 TOTAL INPATIENT PROGRAM CAPITAL 3 4 CAPITAL COST PAYMENT FACTOR 4 5 TOTAL INPATIENT PROGRAM CAPITAL COST 5 PART IV - COMPUTATION OF EXCEPTION PAYMENTS 1 PROGRAM INPATIENT CAPITAL COSTS 1 2 PROGRAM INPATIENT CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES 2 3 NET PROGRAM INPATIENT CAPITAL COSTS 3 4 APPLICABLE EXCEPTION PERCENTAGE 4 5 CAPITAL COST FOR COMPARISON TO PAYMENTS 5 6 PERCENTAGE ADJUSTMENT FOR EXTRAORDINARY CIRCUMSTANCES 6 7 ADJUSTMENT TO CAPITAL MINIMUM PAYMENT LEVEL FOR 7 EXTRAORDINARY CIRCUMSTANCES 8 CAPITAL MINIMUM PAYMENT LEVEL 8 9 CURRENT YEAR CAPITAL PAYMENTS 9 10 CURRENT YEAR COMPARISON OF CAPITAL MINIMUM PAYMENT LEVEL 10 TO CAPITAL PAYMENTS 11 CARRYOVER OF ACCUMULATED CAPITAL MINIMUM PAYMENT LEVEL 11 OVER CAPITAL PAYMENT 12 NET COMPARISON OF CAPITAL MINIMUM PYMNT LEVEL TO CAPITAL PYMNTS 12 13 CURRENT YEAR EXCEPTION PAYMENT 13 14 CARRYOVER OF ACCUMULATED CAPITAL MINIMUM PAYMENT LEVEL 14 OVER CAPITAL PAYMENT FOR FOLLOWING PERIOD 15 CURRENT YEAR ALLOWABLE OPERATING AND CAPITAL PAYMENT 15 (SEE INSTRUCTIONS) 16 CURRENT YEAR OPERATING AND CAPITAL COSTS (SEE INSTRUCTIONS) 16 17 CURRENT YEAR EXCEPTION OFFSET AMOUNT 17 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/29/2009 10:07 CALCULATION OF CAPITAL PAYMENT - TITLE XIX - COST METHOD WORKSHEET L HOSPITAL HOSPITAL SUB I SUB II SUB III (15-0091) (15-0091) 1 1.01 PART I - FULLY PROSPECTIVE METHOD 1 CAPITAL HOSPITAL SPECIFIC RATE PAYMENTS 1 CAPITAL FEDERAL AMOUNT 2 CAPITAL DRG OTHER THAN OUTLIER 2 3 CAPITAL DRG OUTLIER PAYMENTS FOR SERVICES RENDERED 3 PRIOR TO OCTOBER 1, 1997 3.01 CAPITAL DRG OUTLIER PAYMENTS FOR SERVICES RENDERED 3.01 ON OR AFTER OCTOBER 1, 1997 INDIRECT MEDICAL EDUCATION ADJUSTMENT 4 TOTAL INPAT DAYS DIVIDED BY NO OF DAYS IN CR PERIOD 4 4.01 NUMBER OF INTERNS AND RESIDENTS FROM WORKSHEET S-3, PART I 4.01 4.02 INDIRECT MEDICAL EDUCATION PERCENTAGE 4.02 4.03 INDIRECT MEDICAL EDUCATON ADJUSTMENT 4.03 DISPROPORTIONATE SHARE ADJUSTMENT 5 % OF SSI RECIPIENT PAT DAYS TO MEDICARE PART A PAT DAYS 5 5.01 % OF MEDICAID PAT DAYS TO TOTAL DAYS ON WKST S-3, PART I 5.01 5.02 SUM OF LINES 5 AND 5.01 5.02 5.03 ALLOWABLE DISPROPORTIONATE SHARE PERCENTAGE 5.03 5.04 DISPROPORTIONATE SHARE ADJUSTMENT 5.04 6 TOTAL PROSPECTIVE CAPITAL PAYMENTS 6 PART II - HOLD HARMLESS METHOD 1 NEW CAPITAL 1 2 OLD CAPITAL 2 3 TOTAL CAPITAL 3 4 RATIO OF NEW CAPITAL TO TOTAL CAPITAL 4 5 TOTAL CAPITAL PAYMENTS UNDER 100% FEDERAL RATE 5 6 REDUCTION FACTOR FOR HOLD HARMLESS PAYMENT 6 7 REDUCED OLD CAPITAL AMOUNT 7 8 HOLD HARMLESS PAYMENT FOR NEW CAPITAL 8 9 SUBTOTAL 9 10 PAYMENT UNDER HOLD HARMLESS (GREATER OF LINE 5 OR LINE 9) 10 PART III - PAYMENT UNDER REASONABLE COST 1 PROGRAM INPATIENT ROUTINE CAPITAL COST 1 2 PROGRAM INPATIENT ANCILLARY CAPITAL COST 2 3 TOTAL INPATIENT PROGRAM CAPITAL 3 4 CAPITAL COST PAYMENT FACTOR 4 5 TOTAL INPATIENT PROGRAM CAPITAL COST 5 PART IV - COMPUTATION OF EXCEPTION PAYMENTS 1 PROGRAM INPATIENT CAPITAL COSTS 1 2 PROGRAM INPATIENT CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES 2 3 NET PROGRAM INPATIENT CAPITAL COSTS 3 4 APPLICABLE EXCEPTION PERCENTAGE 4 5 CAPITAL COST FOR COMPARISON TO PAYMENTS 5 6 PERCENTAGE ADJUSTMENT FOR EXTRAORDINARY CIRCUMSTANCES 6 7 ADJUSTMENT TO CAPITAL MINIMUM PAYMENT LEVEL FOR 7 EXTRAORDINARY CIRCUMSTANCES 8 CAPITAL MINIMUM PAYMENT LEVEL 8 9 CURRENT YEAR CAPITAL PAYMENTS 9 10 CURRENT YEAR COMPARISON OF CAPITAL MINIMUM PAYMENT LEVEL 10 TO CAPITAL PAYMENTS 11 CARRYOVER OF ACCUMULATED CAPITAL MINIMUM PAYMENT LEVEL 11 OVER CAPITAL PAYMENT 12 NET COMPARISON OF CAPITAL MINIMUM PYMNT LEVEL TO CAPITAL PYMNTS 12 13 CURRENT YEAR EXCEPTION PAYMENT 13 14 CARRYOVER OF ACCUMULATED CAPITAL MINIMUM PAYMENT LEVEL 14 OVER CAPITAL PAYMENT FOR FOLLOWING PERIOD 15 CURRENT YEAR ALLOWABLE OPERATING AND CAPITAL PAYMENT 15 (SEE INSTRUCTIONS) 16 CURRENT YEAR OPERATING AND CAPITAL COSTS (SEE INSTRUCTIONS) 16 17 CURRENT YEAR EXCEPTION OFFSET AMOUNT 17 PROVIDER NO. 15-0091 HUNTINGTON MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:07 ALLOCATION OF ALLOWABLE CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES WORKSHEET L-1 PART I EXTRAORDI- I&R COST & COST CENTER DESCRIPTION NARY CAP- SUBTOTAL SUBTOTAL POST STEP- TOTAL REL COSTS DOWN ADJS 0 4A 25 26 27 GENERAL SERVICE COST CENTERS 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 3 4 NEW CAP REL COSTS-MVBLE EQUIP 4 5 EMPLOYEE BENEFITS 5 6 ADMINISTRATIVE & GENERAL 6 7 MAINTENANCE & REPAIRS 7 8 OPERATION OF PLANT 8 9 LAUNDRY & LINEN SERVICE 9 10 HOUSEKEEPING 10 11 DIETARY 11 12 CAFETERIA 12 13 MAINTENANCE OF PERSONNEL 13 14 NURSING ADMINISTRATION 14 15 CENTRAL SERVICES & SUPPLY 15 16 PHARMACY 16 17 MEDICAL RECORDS & LIBRARY 17 18 SOCIAL SERVICE 18 20 NONPHYSICIAN ANESTHETISTS 20 21 NURSING SCHOOL 21 22 I&R SERVICES-SALARY & FRINGES A 22 23 I&R SERVICES-OTHER PRGM COSTS A 23 24 PARAMED ED PRGM-(SPECIFY) 24 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 25 33 NURSERY 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 37 41 RADIOLOGY-DIAGNOSTIC 41 44 LABORATORY 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 49 RESPIRATORY THERAPY 49 50 PHYSICAL THERAPY 50 51 OCCUPATIONAL THERAPY 51 55 MEDICAL SUPPLIES CHARGED TO PAT 55 56 DRUGS CHARGED TO PATIENTS 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 60 61 EMERGENCY 61 62 OBSERVATION BEDS (NON-DISTINCT 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 71 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 PANCREAS ACQUISITION 85.01 85.02 INTESTINAL ACQUISITION 85.02 95 SUBTOTALS 95 NONREIMBURSABLE COST CENTERS 96 GIFT, FLOWER, COFFEE SHOP & CAN 96 98 PHYSICIANS' PRIVATE OFFICES 98 00 OCC HEALTH 00 00.01 FOUNDATION 00.01 00.02 KIDS KAMPUS 00.02 00.03 COMMUNITY HEALTH IMPROVEMENT 00.03 00.04 HUNTINGTON COLLEGE NURSE 00.04 00.05 MISC CATERING 00.05 00.06 NON-ALLOWED OFFICE SPACE 00.06 101 CROSS FOOT ADJUSTMENTS 101 102 NEGATIVE COST CENTER 102 103 TOTAL 103 104 TOTAL STATISTICAL BASIS 104 105 UNIT COST MULTIPLIER 105 105 UNIT COST MULTIPLIER 105 ***FINGERPRINT Line 1 9DP0fwc8TpjUA.PnPjQm9:B:8OahB0 ***FINGERPRINT Line 2 r5j050QP03ZlIxhDVxTHuNirzN6kwz ***FINGERPRINT Line 3 oxDe6FbRUx0fNAC6