Arizona Rural Health Clinic Designation Manual - Arizona Center for ...

F. RHC Cost Report (con’t)
•Worksheet B
This worksheet is used to summarize the number of facility visits to be used in the rate determination. The
visits include the visits furnished by the provider’s health care staff and any physicians under agreement.
This worksheet also calculates the overhead cost incurred which applies to the services.
•Worksheet B-1
The cost and administration of Pneumococcal and Infl uenza vaccines to Medicare benefi ciaries are 100
percent reimbursable by Medicare. This worksheet calculates the cost per injection of each of these vaccines
and determines the total amount of reimbursement for the vaccines administered to Medicare benefi
ciaries.
•Worksheet C
This worksheet provides for the determination of the provider’s cost per visit and calculates the total amount
due the provider or due the intermediary. Part I calculates the cost per visit and Part II determines the total
Medicare payment due the provider for services furnished to Medicare benefi ciaries. This worksheet also
allows the provider to claim reimbursement for bad debts related to uncollectible Medicare deductible and
coinsurance amounts.
The following is information that needs to be gathered in order to complete a rural health clinic cost report:
1) Financial statements for the cost reporting period; to include the trial balance.
2) Total number of visits for the cost reporting period for each of the following health care providers (individual
by name):
A. Physicians
B. PAs/NPs/CNMs
C.Any Other Health Care Providers (list on worksheet by name and title)
Total visits broken down by the following, per health care provider listed above.
I. Medicare Visits
II. Regular Medicaid Fee-For-Service Visits
III. Crossover Visits (Medicare Primary and Regular Medicaid Secondary)
IV. Medicaid HMO (Qualifi ed Health Plan) Visits per each HMO Crossover Visit (Medicare Primary
and Medicaid HMO Secondary per each HMO)
V. Private Visits (workers’ comp., commercial, self pay, sliding fee, etc.)
3) The clinic’s hours of operation per week.
4) Individual average hours worked per week for the following health care providers:
1. Physicians
2. PA/NP’s
3. Any Other Health Care Providers
5) Total average hours worked per week for each of the above health care providers broken down by the
following:
1. Administrative hours
2. Patient Care hours
3. Inpatient hours
Job titles and wages should be broken down for all employees of the RHC for the cost reporting period. Be
specifi c for those employees related to a lab technician job description for actual hours worked as “lab tech”
and other hours worked.
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