State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 31 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References SAN FRANCISCO GENERAL HOSPITAL Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W Cost Report ADJUSTMENTS TO REPORTED COSTS 9 10A A 6.00 7 Administrative and General * $85,292,593 ($201,232) $85,091,361 To reverse the provider's unallocated variance adjustment to agree with the provider's record and due to lack of documentations. CMS Pub. 15-1, Sections 2300 and 2304 10 10A A 4.00 7 New Capital Related Costs - Moveable Equipment $3,079,983 $39,064 $3,119,047 To adjust depreciation expense to agree with the provider's depreciation schedule. CMS Pub. 15-1, Sections 102, 2300, 2302.4, and 2304 11 10A A 63.60 7 Adult Medical Center FQHC I * $15,900,440 $3,533,337 $19,433,777 10A A 63.61 7 Women's Health Center FQHC II * 6,068,758 1,106,124 7,174,882 10A A 63.62 7 Family Health Center FQHC III * 5,235,592 1,713,092 6,948,684 10A A 63.63 7 Children's Health Center FQHC IV * 3,549,578 856,995 4,406,573 To reverse the provider's elimination of FQHC physician expenses to agree with the provider's supporting documentations and for proper cost determination. CMS Pub. 15-1, Sections 2300, 2302, 2304, and 2306 *Balance carried forward from prior/to subsequent adjustments Page 5 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 31 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References SAN FRANCISCO GENERAL HOSPITAL Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W Cost Report ADJUSTMENTS TO REPORTED STATISTICS 12 9 B-1 61.01 5 Psych Emergency (Gross Salaries) 4,817,197 (1,118,941) 3,698,256 9 B-1 96.01 5 Other Than Hospital 9,997,842 1,118,941 11,116,783 To adjust gross salaries statistics to agree with the provider's records and in conjunction with audit adjustment number 2. CMS Pub. 15-1, Sections 2300, 2304, and 2306 13 9 B-1 61.01 12 Psych Emergency (Full Time Equivalents) 3,736 (687) 3,049 9 B-1 96.01 12 Other Than Hospital 6,896 687 7,583 To adjust Cafeteria statistics to agree with the provider's records. CMS Pub. 15-1, Sections 2300, 2304, and 2306 14 9 B-1 61.01 14 Psych Emergency (Nursing Full Time Equivalents) 2,304 (310) 1,994 9 B-1 96.01 14 Other Than Hospital 4,368 310 4,678 To adjust Nursing Administration statistics to agree with the provider's records. CMS Pub. 15-1, Sections 2300, 2304, and 2306 15 9 B-1 61.01 15 Psych Emergency (Costed Requisitions) 7,118 (2,117) 5,001 9 B-1 96.01 15 Other Than Hospital 99,498 2,117 101,615 To adjust costed requisitions statistics to agree with the provider's records. CMS Pub. 15-1, Sections 2300, 2304, and 2306 16 9 B-1 55.00 15 Medical Supplies Charged to Patients (Costed Requisitions) 6,936,471 (4,405,182) 2,531,289 9 B-1 15.00 15 Total Statistics - Costed Requisitions 25,359,374 (4,405,182) 20,954,192 To adjust costed requisitions statistics to agree with the provider's records and for proper cost determination. CMS Pub. 15-1, Sections 2300, 2304, and 2306 17 9 B-1 61.01 16 Psych Emergency (Costed Requisitions) 25,341 (18,946) 6,395 9 B-1 96.01 16 Other Than Hospital 842,701 18,946 861,647 To adjust costed requisitions statistics to agree with the provider's records. CMS Pub. 15-1, Sections 2300, 2304, and 2306 Page 6 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 31 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References SAN FRANCISCO GENERAL HOSPITAL Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W Cost Report ADJUSTMENTS TO REPORTED STATISTICS 18 9 B-1 56.00 17, 18 Drugs Charged to Patients (Gross Charges) 163,163,510 32,440,245 195,603,755 9 B-1 17.00 17 Total Statistics - Gross Charges 1,396,604,442 32,440,245 1,429,044,687 9 B-1 18.00 18 Total Statistics - Gross Charges 1,396,604,442 32,440,245 1,429,044,687 To adjust Medical Records and Social Service statistics in conjunction with audit adjustment number 21. CMS Pub. 15-1, Sections 2300, 2304, and 2306 19 9 B-1 25.00 22 Adults and Pediatrics (Assigned Time) 21,347 1,594 22,941 9 B-1 37.00 22 Operating Room 7,886 (82) 7,804 9 B-1 40.00 22 Anesthesiology 4,898 78 4,976 9 B-1 41.00 22 Radiology - Diagnostic 4,175 253 4,428 9 B-1 44.01 22 Laboratory Pathology 3,739 507 4,246 9 B-1 60.00 22 Clinic 40,447 6,065 46,512 9 B-1 61.00 22 Emergency 2,127 827 2,954 9 B-1 63.60 22 Adult Medical Center FQHC I 4,591 1,440 6,031 9 B-1 63.61 22 Women's Health Center FQHC II 3,141 1,560 4,701 9 B-1 63.62 22 Family Health Center FQHC III 3,162 2,357 5,519 9 B-1 63.63 22 Children's Health Center FQHC IV 2,786 1,213 3,999 9 B-1 63.64 22 Urgent Care FQHC V 1,703 677 2,380 9 B-1 22.00 22 Total Statistics - Assigned Time 100,002 16,489 116,491 To adjust Interns and Residents statistics to agree with the provider's supporting documents. CMS Pub. 15-1, Sections 2300, 2304, and 2306 Page 7 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 31 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References SAN FRANCISCO GENERAL HOSPITAL Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W Cost Report ADJUSTMENT TO REPORTED TOTAL CHARGES 20 5, DPH 5 C I 56.00 8 Drugs Charged to Patients $163,163,510 $27,175,934 $190,339,444 To adjust total Drugs Charged to Patients for proper matching of revenue and expenses and to agree with the provider's records. CMS Pub. 15-1, Sections 2102, 2202.4, 2206 2302.6, 2304, 2306, 2204, 2300, and 2304 Page 8 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 31 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References SAN FRANCISCO GENERAL HOSPITAL Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W Cost Report ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - DESIGNATED PUBLIC HOSPITAL (DPH) 21 DPH 4 D-1 I XIX 9.00 1 Medi-Cal Days - Adults and Pediatrics 32,744 (5,099) 27,645 * DPH 4A D-1 II XIX 42.00 4 Medi-Cal Days - Nursery 1,567 14 1,581 DPH 4A D-1 II XIX 43.00 4 Medi-Cal Days - Intensive Care Unit 2,609 474 3,083 DPH 4A D-1 II XIX 44.00 4 Medi-Cal Days - Coronary Care Unit 7 (1) 6 DPH 4A D-1 II XIX 47.00 4 Medi-Cal Days - Neonatal Intensive Care Unit 370 26 396 22 DPH 6 D-4 XIX 37.00 2 Medi-Cal Ancillary Charges - Operating Room $15,322,515 $2,947,284 $18,269,799 DPH 6 D-4 XIX 39.00 2 Medi-Cal Ancillary Charges - Delivery Room and Labor Room 1,597,863 (1,596,070) 1,793 DPH 6 D-4 XIX 40.00 2 Medi-Cal Ancillary Charges - Anesthesiology 11,192,897 2,435,045 13,627,942 DPH 6 D-4 XIX 41.00 2 Medi-Cal Ancillary Charges - Radiology - Diagnostic 13,318,217 363,215 13,681,432 * DPH 6 D-4 XIX 44.00 2 Medi-Cal Ancillary Charges - Laboratory 19,463,335 1,176,541 20,639,876 * DPH 6 D-4 XIX 44.01 2 Medi-Cal Ancillary Charges - Laboratory - Pathology 1,111,037 71,374 1,182,411 DPH 6 D-4 XIX 46.00 2 Medi-Cal Ancillary Charges - Whole Blood and Packed Red Blood 1,549,612 444,250 1,993,862 DPH 6 D-4 XIX 49.00 2 Medi-Cal Ancillary Charges - Respiratory Therapy 2,728,726 538,596 3,267,322 DPH 6 D-4 XIX 50.00 2 Medi-Cal Ancillary Charges - Physical Therapy 2,067,788 518,198 2,585,986 * DPH 6 D-4 XIX 51.00 2 Medi-Cal Ancillary Charges - Occupational Therapy 1,045,026 (596,556) 448,470 * DPH 6 D-4 XIX 53.00 2 Medi-Cal Ancillary Charges - Electrocardiology 2,320,068 696,167 3,016,235 DPH 6 D-4 XIX 55.00 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 21,082,150 4,440,029 25,522,179 DPH 6 D-4 XIX 55.01 2 Medi-Cal Ancillary Charges - Implantable Devices 63,025 110,879 173,904 DPH 6 D-4 XIX 56.00 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 38,694,153 1,079,482 39,773,635 * DPH 6 D-4 XIX 57.00 2 Medi-Cal Ancillary Charges - Renal Dialysis 705,059 (58,703) 646,356 DPH 6 D-4 XIX 59.00 2 Medi-Cal Ancillary Charges - Other Ancillaries 173,365 8,893 182,258 DPH 6 D-4 XIX 61.00 2 Medi-Cal Ancillary Charges - Emergency 6,931,462 887,389 7,818,851 DPH 6 D-4 XIX 101.00 2 Medi-Cal Ancillary Charges - Total 139,371,813 13,466,013 152,837,826 * 23 DPH 2 E-3 III XIX 10.00 1 Medi-Cal Routine Service Charges $171,200,845 ($13,084,165) $158,116,680 * DPH 2 E-3 III XIX 11.00 1 Medi-Cal Ancillary Service Charges 139,371,813 13,466,013 152,837,826 * 24 DPH 3 E-3 III XIX 33.00 1 Medi-Cal Deductibles $0 $179,610 $179,610 * DPH 3 E-3 III XIX 36.00 1 Medi-Cal Coinsurance 500,281 (108,870) 391,411 * DPH 1 E-3 III XIX 57.00 1 Medi-Cal Interim Payments 47,718,905 4,456,875 52,175,780 * -Continued on next page- *Balance carried forward from prior/to subsequent adjustments Page 9 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 31 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References SAN FRANCISCO GENERAL HOSPITAL Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W Cost Report ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - DESIGNATED PUBLIC HOSPITAL (DPH) -Continued from previous page- To adjust Medi-Cal Settlement Data to agree with the following EDS Paid Claims Summary: Report Date: January 26, 2011 Payment Period: July 1, 2008 through January 11, 2011 Service Period: July 1, 2008 through June 30, 2009 CMS Pub. 15-1, Sections 2304 and 2408.3 Page 10 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 31 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References SAN FRANCISCO GENERAL HOSPITAL Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W Cost Report ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - DESIGNATED PUBLIC HOSPITAL (DPH) 25 DPH 4 D-1 I XIX 9.00 1 Medi-Cal Days - Adults and Pediatrics (Administrative Days) * 27,645 8,353 35,998 26 DPH 6 D-6 I XIX 41.00 2 Medi-Cal Ancillary Charges - Radiology - Diagnostic * $13,681,432 $99,492 $13,780,924 DPH 6 D-6 I XIX 44.00 2 Medi-Cal Ancillary Charges - Laboratory * 20,639,876 1,179,334 21,819,210 DPH 6 D-6 I XIX 50.00 2 Medi-Cal Ancillary Charges - Physical Therapy * 2,585,986 565,718 3,151,704 DPH 6 D-6 I XIX 51.00 2 Medi-Cal Ancillary Charges - Occupational Therapy * 448,470 153,712 602,182 DPH 6 D-6 I XIX 56.00 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients * 39,773,635 4,556,026 44,329,661 DPH 6 D-4 XIX 101.00 2 Medi-Cal Ancillary Charges - Total * 152,837,826 6,554,282 159,392,108 27 DPH 2 E-3 III XIX 10.00 1 Medi-Cal Routine Service Charges * $158,116,680 $35,260,046 $193,376,726 DPH 2 E-3 III XIX 11.00 1 Medi-Cal Ancillary Service Charges * 152,837,826 6,554,282 159,392,108 28 DPH 3 E-3 III XIX 33.00 1 Medi-Cal Deductibles * $179,610 $11,432 $191,042 DPH 3 E-3 III XIX 36.00 1 Medi-Cal Coinsurance * 391,411 38,747 430,158 DPH 1 E-3 III XIX 57.00 1 Medi-Cal Interim Payments * 52,175,780 5,004,939 57,180,719 In accordance with SB 1115 waiver, Administrative Days will be combined with the Designated Public Hospital Settlement. This adjustment is to include Medi-Cal Administrative Days with the Designated Public Hospital Settlement and to agree with the following EDS Paid Claims Summary: Report Date: January 26, 2011 Payment Period: July 1, 2008 through January 11, 2011 Service Period: July 1, 2008 through June 30, 2009 CMS Pub. 15-1, Sections 2304 and 2408.3 *Balance carried forward from prior/to subsequent adjustments Page 11 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 31 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References SAN FRANCISCO GENERAL HOSPITAL Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W Cost Report ADJUSTMENTS TO OTHER MATTERS 29 DPNF 1 S-3 I 25.00 1 Total Hospital Licensed Capacity (All Levels) 477 121 598 To adjust the reported Skilled Nursing Facility licensed capacity and total hospital licensed capacity to reflect the Department of Health Services bed license, effective during the fiscal year ended June 30, 2009. CMS Pub. 15-1, Section 2304 30 DPNF 1 D-1 I 1.00 9 Medi-Cal Days - Skilled Nursing Facility 0 14,113 14,113 To adjust Medi-Cal Settlement Data to agree with the following EDS Paid Claims Summary: Report Date: January 26, 2011 Payment Period: July 1, 2008 through January 11, 2011 Service Period: July 1, 2008 through June 30, 2009 CMS Pub. 15-1, Sections 2304 and 2408.3 31 DPH 1 Not Reported Medi-Cal Overpayments $0 $1,607 $1,607 To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed. CCR, Title 22, Sections 50786 and 51458.1 CMS Pub. 15-1, Sections 2300 and 2409 Page 12 This is trial version www.adultpdf.com . State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 31 Adj. Audit Work As. prior/to subsequent adjustments Page 5 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 31 Adj. Audit Work As. Sections 2300, 2304, and 2306 Page 7 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 31 Adj. Audit Work As