92422 Financial and Statistical Data Report

Office of Hospital Facilities Transactional Forms for FHA Programs 242, 241, 223(f), 223(a)(7)

HUD-92422 Finan and Stat Data Rept.xlsx

Hospital Facilities projects pursuant to FHA Programs 242, 241, 223(f), 223(a)(7)

OMB: 2502-0602

Document [xlsx]
Download: xlsx | pdf

Overview

For Quarterly Reporting Only
Monthly Reporting - 1st Qtr
Monthly Reporting - 2nd Qtr
Monthly Reporting - 3rd Qtr
Monthly Reporting - 4th Qtr


Sheet 1: For Quarterly Reporting Only

FINANCIAL AND STATISTICAL DATA FOR HUD REPORTING
ENTER HOSPITAL NAME HERE ENTER FYE HERE

If monthly reporting is required enter 1, if quarterly enter 2



Instructions:





(A.) Please call your OIHCF Account Executive for any clarifications.





(B.) For the FY quarter that you are completing, a value must be entered for all cells highlighted in yellow





(C.) All line items in your financials must be summarized on this worksheet (e.g., if you have a current asset on your balance sheet and there is no





specific line on this worksheet for it, then it should be included in "All Other Current Assets")





(D.) Footnotes, which provide an explanation of some lines, are located on Page 4.












Description Entry Label 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr


YTD YTD YTD YTD
Balance Sheet





Cash & Temporary Investments R06




Gross Patient Receivables





Allowance for Doubtful Accounts R32




Net Accounts Receivable R07




All Other Current Assets





Total Current Assets R09




Long Term Investments R33




Limited Use or Desginated Assets R10




Gross Property, Plant & Equipment





Accumulated Depreciation R11




Net Property, Plant & Equipment R12




All Other Non-current Assets





Total Assets R13











Accounts Payable & Accrued Expenses H01




Current Portion of LT Debts R14




All Other Current Liabilities





Total Current Liabilities R15




Long Term Capital Debt R16




All Other Long Term Liabilities





Total Long Term Liabilities





Total Liabilities R17




Unrestricted Fund Balance R18




Temporarily Restricted Fund Balance R39




Restricted Fund Balance R19




Total Net Assets





Total Net Assets + Total Liabilities












Income Statement





Net Inpatient Revenue (1) (6) H02




Net Outpatient Revenue (1) (6) H03




Total Net Patient Revenue (1) R20




All Other Operating Revenue





Total Operating Revenue R21











Salaries & Wages H05




Employee Benefits R36




Total Supplies Expense H04




Depreciation & Amortization Expense R22




Interest Expense R23




Bad Debt Expense (1) R24




All Other Operating Expenses





Total Operating Expense R25




Income from Operations












All Non-Operating Revenue H06




All Non-Operating Expense H07




Extraordinary Items & Income Taxes R26




Net Income R27











Unrecognized Gains/Losses R28




Other Changes in Fund Balance (2) R30




Net Increase/Decrease in Fund Balance












Mortage Reserve Fund





Required MRF Balance H11




Actual MRF Balance H12




Net Inpatient Revenue (1)





Medicare H13




Medicaid H14




Blue Cross H15




Commercial Insurance H16




HMO/Managed Care H17




Self Pay H18




Other H45




Inpatient Utilization





Total Licensed Beds H19




Total Staffed Beds H20




Acute Medical/Surgical Service





Number of Beds H21




Discharges H22




Patient Days H23




Newborn Service





Number of Beds H24




Discharges H25




Patient Days H26




Other Acute Care Services





Number of Beds H27




Discharges H28




Patient Days H29




Other Non-Acute Care





Number of Beds H30




Discharges H31




Patient Days H32




Acute Care Only (Excl. Newborn)





Medicare





Case Mix Index (3) H33




ALOS (5) H34




Non-Medicare





Case Mix Index (3) H35




ALOS (5) H36




All Patients





Case Mix Index (3) H37




ALOS (5) H38




Inpatient Cost per Discharge H39




Outpatient Utilization





Emergency Room Visits H40




Ambulatory Surgery H41




Clinic Visits H42




Other Outpatient Visits H43




Staffing





Total Full-Time Equivalents (4) H44


















Footnotes:





(1) Bad Debt Expense is recorded as a separate line item, not as a component of net patient revenue.





(2) Please provide an explanation for any "Other Changes in Fund Balance".





(3) Please enter using only 2 decimal points





(4) Please enter using only a whole number





(5) Please enter using only 1 decimal point





(6) These are estimates. To estimate the Net Inpatient Revenue, use the percentage of Gross Inpatient Revenue to Gross Total Patient Revenue.



















Edit Checks
Edit Satisfied? Edit Satisfied? Edit Satisfied? Edit Satisfied?
Balance Sheet





A15-A16=A17
Yes Yes Yes Yes
A14+A17+A18=A19
Yes Yes Yes Yes
A19+A20+A21+A24+A25=A26
Yes Yes Yes Yes
A28+A29+A30=A31
Yes Yes Yes Yes
A32+A33=A34
Yes Yes Yes Yes
A31+A34=A35
Yes Yes Yes Yes
A36+A37+A38=A39
Yes Yes Yes Yes
A35+A39=A40
Yes Yes Yes Yes







Income Statement





A43+A44=A45
Yes Yes Yes Yes
A45+A46=A47
Yes Yes Yes Yes
A49+A50+A51+A52+A53+A54+A55=A56
Yes Yes Yes Yes
A57+A59-A60-A61=A62
Yes Yes Yes Yes
A62+A64+A65=A66
Yes Yes Yes Yes
A72+A73+A74+A75+A76+A77+A78=A43
Yes Yes Yes Yes







Various Edit Checks





R20<=R21
Yes Yes Yes Yes total net patient revenue < or = total operating revenue
R21-R25+H6-H7+R26=R27
Yes Yes Yes Yes tot op rev - tot op exp + non op rev - non op exp - extraordinary items = net income
H4+H5+R22+R23+R24<=R25
Yes Yes Yes Yes tot supplies exp + tot sale & benefits + deep exp + into exp + bad debt exp <= tot op exp
R6+R7+R8<=R9
Yes Yes Yes Yes cash & temp invest + net AR + inventories<= tot currents assets
R9+R10+R12<=R13
Yes Yes Yes Yes tot currents assets + limited use assets + net fixed assets <= tot assets
R13=R17+R18
Yes Yes Yes Yes total assets = total liabilities + unrestricted fund balance
H1+R14<=R15
Yes Yes Yes Yes AP & accrued exp + current portion LT debt <= total liabilities
R!5+R16<=R17
Yes Yes Yes Yes total current lab + LT capital debt = total liabilities







Reasonableness Review for Cost per Discharge
#DIV/0! #DIV/0! #DIV/0! #DIV/0!

Sheet 2: Monthly Reporting - 1st Qtr

FINANCIAL AND STATISTICAL DATA FOR HUD REPORTING
ENTER FYE HERE
ENTER HOSPITAL NAME HERE

If monthly reporting is required enter 1, if quarterly enter 2



Instructions:





(A.) Please call your OIHCF Account Executive for any clarifications.





(B.) For the FY month that you are completing, a value must be entered for all cells highlighted in yellow





(C.) All line items in your financials must be summarized on this worksheet (e.g., if you have a current asset on your balance sheet and there is no





specific line on this worksheet for it, then it should be included in "All Other Current Assets")





(D.) Footnotes, which provide an explanation of some lines, are located on Page 4.



















Description Entry Label 1st Month 2nd Month 3rd Month Do not Use - Start New Spreadsheet


YTD YTD YTD YTD
Balance Sheet





Cash & Temporary Investments R06




Gross Patient Receivables





Allowance for Doubtful Accounts R32




Net Accounts Receivable R07




All Other Current Assets





Total Current Assets R09




Long Term Investments R33




Limited Use or Desginated Assets R10




Gross Property, Plant & Equipment





Accumulated Depreciation R11




Net Property, Plant & Equipment R12




All Other Non-current Assets





Total Assets R13











Accounts Payable & Accrued Expenses H01




Current Portion of LT Debts R14




All Other Current Liabilities





Total Current Liabilities R15




Long Term Capital Debt R16




All Other Long Term Liabilities





Total Long Term Liabilities





Total Liabilities R17




Unrestricted Fund Balance R18




Temporarily Restricted Fund Balance R39




Restricted Fund Balance R19




Total Net Assets





Total Net Assets + Total Liabilities












Income Statement





Net Inpatient Revenue (1) (6) H02




Net Outpatient Revenue (1) (6) H03




Total Net Patient Revenue (1) R20




All Other Operating Revenue





Total Operating Revenue R21











Salaries & Wages H05




Employee Benefits R36




Total Supplies Expense H04




Depreciation & Amortization Expense R22




Interest Expense R23




Bad Debt Expense (1) R24




All Other Operating Expenses





Total Operating Expense R25




Income from Operations












All Non-Operating Revenue H06




All Non-Operating Expense H07




Extraordinary Items & Income Taxes R26




Net Income R27











Unrecognized Gains/Losses R28




Other Changes in Fund Balance (2) R30




Net Increase/Decrease in Fund Balance












Mortage Reserve Fund





Required MRF Balance H11




Actual MRF Balance H12




Net Inpatient Revenue (1)





Medicare H13




Medicaid H14




Blue Cross H15




Commercial Insurance H16




HMO/Managed Care H17




Self Pay H18




Other H45




Inpatient Utilization





Total Licensed Beds H19




Total Staffed Beds H20




Acute Medical/Surgical Service





Number of Beds H21




Discharges H22




Patient Days H23




Newborn Service





Number of Beds H24




Discharges H25




Patient Days H26




Other Acute Care Services





Number of Beds H27




Discharges H28




Patient Days H29




Other Non-Acute Care





Number of Beds H30




Discharges H31




Patient Days H32




Acute Care Only (Excl. Newborn)





Medicare





Case Mix Index (3) H33




ALOS (5) H34




Non-Medicare





Case Mix Index (3) H35




ALOS (5) H36




All Patients





Case Mix Index (3) H37




ALOS (5) H38




Inpatient Cost per Discharge H39




Outpatient Utilization





Emergency Room Visits H40




Ambulatory Surgery H41




Clinic Visits H42




Other Outpatient Visits H43




Staffing





Total Full-Time Equivalents (4) H44


















Footnotes:





(1) Bad Debt Expense is recorded as a separate line item, not as a component of net patient revenue.





(2) Please provide an explanation for any "Other Changes in Fund Balance".





(3) Please enter using only 2 decimal points





(4) Please enter using only a whole number





(5) Please enter using only 1 decimal point





(6) These are estimates. To estimate the Net Inpatient Revenue, use the percentage of Gross Inpatient Revenue to Gross Total Patient Revenue.



















Edit Checks
Edit Satisfied? Edit Satisfied? Edit Satisfied? Edit Satisfied?
Balance Sheet





A17-A18=A19
Yes Yes Yes Yes
A16+A19+A20=A21
Yes Yes Yes Yes
A21+A22+A23+A26+A27=A28
Yes Yes Yes Yes
A30+A31+A32=A33
Yes Yes Yes Yes
A34+A35=A36
Yes Yes Yes Yes
A33+A36=A37
Yes Yes Yes Yes
A38+A39+A40=A41
Yes Yes Yes Yes
A37+A41=A42
Yes Yes Yes Yes







Income Statement





A45+A46=A47
Yes Yes Yes Yes
A47+A48=A49
Yes Yes Yes Yes
A51+A52+A53+A54+A55+A56+A57=A58
Yes Yes Yes Yes
A59+A61-A62-A63=A64
Yes Yes Yes Yes
A64+A66+A67=A68
Yes Yes Yes Yes
A74+A75+A76+A77+A78+A79+A80=A45
Yes Yes Yes Yes







Various Edit Checks





R20<=R21
Yes Yes Yes Yes total net patient revenue < or = total operating revenue
R21-R25+H6-H7+R26=R27
Yes Yes Yes Yes tot op rev - tot op exp + non op rev - non op exp - extraordinary items = net income
H4+H5+R22+R23+R24<=R25
Yes Yes Yes Yes tot supplies exp + tot sale & benefits + deep exp + into exp + bad debt exp <= tot op exp
R6+R7+R8<=R9
Yes Yes Yes Yes cash & temp invest + net AR + inventories<= tot currents assets
R9+R10+R12<=R13
Yes Yes Yes Yes tot currents assets + limited use assets + net fixed assets <= tot assets
R13=R17+R18
Yes Yes Yes Yes total assets = total liabilities + unrestricted fund balance
H1+R14<=R15
Yes Yes Yes Yes AP & accrued exp + current portion LT debt <= total liabilities
R!5+R16<=R17
Yes Yes Yes Yes total current lab + LT capital debt = total liabilities







Reasonableness Review for Cost per Discharge
#DIV/0! #DIV/0! #DIV/0! #DIV/0!

Sheet 3: Monthly Reporting - 2nd Qtr

FINANCIAL AND STATISTICAL DATA FOR HUD REPORTING
ENTER FYE HERE
ENTER HOSPITAL NAME HERE

If monthly reporting is required enter 1, if quarterly enter 2



Instructions:





(A.) Please call your OIHCF Account Executive for any clarifications.





(B.) For the FY month that you are completing, a value must be entered for all cells highlighted in yellow





(C.) All line items in your financials must be summarized on this worksheet (e.g., if you have a current asset on your balance sheet and there is no





specific line on this worksheet for it, then it should be included in "All Other Current Assets")





(D.) Footnotes, which provide an explanation of some lines, are located on Page 4.



















Description Entry Label 4th Month 5th Month 6th Month Do not Use - Start New Spreadsheet


YTD YTD YTD YTD
Balance Sheet





Cash & Temporary Investments R06




Gross Patient Receivables





Allowance for Doubtful Accounts R32




Net Accounts Receivable R07




All Other Current Assets





Total Current Assets R09




Long Term Investments R33




Limited Use or Desginated Assets R10




Gross Property, Plant & Equipment





Accumulated Depreciation R11




Net Property, Plant & Equipment R12




All Other Non-current Assets





Total Assets R13











Accounts Payable & Accrued Expenses H01




Current Portion of LT Debts R14




All Other Current Liabilities





Total Current Liabilities R15




Long Term Capital Debt R16




All Other Long Term Liabilities





Total Long Term Liabilities





Total Liabilities R17




Unrestricted Fund Balance R18




Temporarily Restricted Fund Balance R39




Restricted Fund Balance R19




Total Net Assets





Total Net Assets + Total Liabilities












Income Statement





Net Inpatient Revenue (1) (6) H02




Net Outpatient Revenue (1) (6) H03




Total Net Patient Revenue (1) R20




All Other Operating Revenue





Total Operating Revenue R21











Salaries & Wages H05




Employee Benefits R36




Total Supplies Expense H04




Depreciation & Amortization Expense R22




Interest Expense R23




Bad Debt Expense (1) R24




All Other Operating Expenses





Total Operating Expense R25




Income from Operations












All Non-Operating Revenue H06




All Non-Operating Expense H07




Extraordinary Items & Income Taxes R26




Net Income R27











Unrecognized Gains/Losses R28




Other Changes in Fund Balance (2) R30




Net Increase/Decrease in Fund Balance












Mortage Reserve Fund





Required MRF Balance H11




Actual MRF Balance H12




Net Inpatient Revenue (1)





Medicare H13




Medicaid H14




Blue Cross H15




Commercial Insurance H16




HMO/Managed Care H17




Self Pay H18




Other H45




Inpatient Utilization





Total Licensed Beds H19




Total Staffed Beds H20




Acute Medical/Surgical Service





Number of Beds H21




Discharges H22




Patient Days H23




Newborn Service





Number of Beds H24




Discharges H25




Patient Days H26




Other Acute Care Services





Number of Beds H27




Discharges H28




Patient Days H29




Other Non-Acute Care





Number of Beds H30




Discharges H31




Patient Days H32




Acute Care Only (Excl. Newborn)





Medicare





Case Mix Index (3) H33




ALOS (5) H34




Non-Medicare





Case Mix Index (3) H35




ALOS (5) H36




All Patients





Case Mix Index (3) H37




ALOS (5) H38




Inpatient Cost per Discharge H39




Outpatient Utilization





Emergency Room Visits H40




Ambulatory Surgery H41




Clinic Visits H42




Other Outpatient Visits H43




Staffing





Total Full-Time Equivalents (4) H44


















Footnotes:





(1) Bad Debt Expense is recorded as a separate line item, not as a component of net patient revenue.





(2) Please provide an explanation for any "Other Changes in Fund Balance".





(3) Please enter using only 2 decimal points





(4) Please enter using only a whole number





(5) Please enter using only 1 decimal point





(6) These are estimates. To estimate the Net Inpatient Revenue, use the percentage of Gross Inpatient Revenue to Gross Total Patient Revenue.



















Edit Checks
Edit Satisfied? Edit Satisfied? Edit Satisfied? Edit Satisfied?
Balance Sheet





A17-A18=A19
Yes Yes Yes Yes
A16+A19+A20=A21
Yes Yes Yes Yes
A21+A22+A23+A26+A27=A28
Yes Yes Yes Yes
A30+A31+A32=A33
Yes Yes Yes Yes
A34+A35=A36
Yes Yes Yes Yes
A33+A36=A37
Yes Yes Yes Yes
A38+A39+A40=A41
Yes Yes Yes Yes
A37+A41=A42
Yes Yes Yes Yes







Income Statement





A45+A46=A47
Yes Yes Yes Yes
A47+A48=A49
Yes Yes Yes Yes
A51+A52+A53+A54+A55+A56+A57=A58
Yes Yes Yes Yes
A59+A61-A62-A63=A64
Yes Yes Yes Yes
A64+A66+A67=A68
Yes Yes Yes Yes
A74+A75+A76+A77+A78+A79+A80=A45
Yes Yes Yes Yes







Various Edit Checks





R20<=R21
Yes Yes Yes Yes total net patient revenue < or = total operating revenue
R21-R25+H6-H7+R26=R27
Yes Yes Yes Yes tot op rev - tot op exp + non op rev - non op exp - extraordinary items = net income
H4+H5+R22+R23+R24<=R25
Yes Yes Yes Yes tot supplies exp + tot sale & benefits + deep exp + into exp + bad debt exp <= tot op exp
R6+R7+R8<=R9
Yes Yes Yes Yes cash & temp invest + net AR + inventories<= tot currents assets
R9+R10+R12<=R13
Yes Yes Yes Yes tot currents assets + limited use assets + net fixed assets <= tot assets
R13=R17+R18
Yes Yes Yes Yes total assets = total liabilities + unrestricted fund balance
H1+R14<=R15
Yes Yes Yes Yes AP & accrued exp + current portion LT debt <= total liabilities
R!5+R16<=R17
Yes Yes Yes Yes total current lab + LT capital debt = total liabilities







Reasonableness Review for Cost per Discharge
#DIV/0! #DIV/0! #DIV/0! #DIV/0!

Sheet 4: Monthly Reporting - 3rd Qtr

FINANCIAL AND STATISTICAL DATA FOR HUD REPORTING
ENTER FYE HERE
ENTER HOSPITAL NAME HERE

If monthly reporting is required enter 1, if quarterly enter 2



Instructions:





(A.) Please call your OIHCF Account Executive for any clarifications.





(B.) For the FY month that you are completing, a value must be entered for all cells highlighted in yellow





(C.) All line items in your financials must be summarized on this worksheet (e.g., if you have a current asset on your balance sheet and there is no





specific line on this worksheet for it, then it should be included in "All Other Current Assets")





(D.) Footnotes, which provide an explanation of some lines, are located on Page 4.



















Description Entry Label 7th Month 8th Month 9th Month Do not Use - Start New Spreadsheet


YTD YTD YTD YTD
Balance Sheet





Cash & Temporary Investments R06




Gross Patient Receivables





Allowance for Doubtful Accounts R32




Net Accounts Receivable R07




All Other Current Assets





Total Current Assets R09




Long Term Investments R33




Limited Use or Desginated Assets R10




Gross Property, Plant & Equipment





Accumulated Depreciation R11




Net Property, Plant & Equipment R12




All Other Non-current Assets





Total Assets R13











Accounts Payable & Accrued Expenses H01




Current Portion of LT Debts R14




All Other Current Liabilities





Total Current Liabilities R15




Long Term Capital Debt R16




All Other Long Term Liabilities





Total Long Term Liabilities





Total Liabilities R17




Unrestricted Fund Balance R18




Temporarily Restricted Fund Balance R39




Restricted Fund Balance R19




Total Net Assets





Total Net Assets + Total Liabilities












Income Statement





Net Inpatient Revenue (1) (6) H02




Net Outpatient Revenue (1) (6) H03




Total Net Patient Revenue (1) R20




All Other Operating Revenue





Total Operating Revenue R21











Salaries & Wages H05




Employee Benefits R36




Total Supplies Expense H04




Depreciation & Amortization Expense R22




Interest Expense R23




Bad Debt Expense (1) R24




All Other Operating Expenses





Total Operating Expense R25




Income from Operations












All Non-Operating Revenue H06




All Non-Operating Expense H07




Extraordinary Items & Income Taxes R26




Net Income R27











Unrecognized Gains/Losses R28




Other Changes in Fund Balance (2) R30




Net Increase/Decrease in Fund Balance












Mortage Reserve Fund





Required MRF Balance H11




Actual MRF Balance H12




Net Inpatient Revenue (1)





Medicare H13




Medicaid H14




Blue Cross H15




Commercial Insurance H16




HMO/Managed Care H17




Self Pay H18




Other H45




Inpatient Utilization





Total Licensed Beds H19




Total Staffed Beds H20




Acute Medical/Surgical Service





Number of Beds H21




Discharges H22




Patient Days H23




Newborn Service





Number of Beds H24




Discharges H25




Patient Days H26




Other Acute Care Services





Number of Beds H27




Discharges H28




Patient Days H29




Other Non-Acute Care





Number of Beds H30




Discharges H31




Patient Days H32




Acute Care Only (Excl. Newborn)





Medicare





Case Mix Index (3) H33




ALOS (5) H34




Non-Medicare





Case Mix Index (3) H35




ALOS (5) H36




All Patients





Case Mix Index (3) H37




ALOS (5) H38




Inpatient Cost per Discharge H39




Outpatient Utilization





Emergency Room Visits H40




Ambulatory Surgery H41




Clinic Visits H42




Other Outpatient Visits H43




Staffing





Total Full-Time Equivalents (4) H44


















Footnotes:





(1) Bad Debt Expense is recorded as a separate line item, not as a component of net patient revenue.





(2) Please provide an explanation for any "Other Changes in Fund Balance".





(3) Please enter using only 2 decimal points





(4) Please enter using only a whole number





(5) Please enter using only 1 decimal point





(6) These are estimates. To estimate the Net Inpatient Revenue, use the percentage of Gross Inpatient Revenue to Gross Total Patient Revenue.



















Edit Checks
Edit Satisfied? Edit Satisfied? Edit Satisfied? Edit Satisfied?
Balance Sheet





A17-A18=A19
Yes Yes Yes Yes
A16+A19+A20=A21
Yes Yes Yes Yes
A21+A22+A23+A26+A27=A28
Yes Yes Yes Yes
A30+A31+A32=A33
Yes Yes Yes Yes
A34+A35=A36
Yes Yes Yes Yes
A33+A36=A37
Yes Yes Yes Yes
A38+A39+A40=A41
Yes Yes Yes Yes
A37+A41=A42
Yes Yes Yes Yes







Income Statement





A45+A46=A47
Yes Yes Yes Yes
A47+A48=A49
Yes Yes Yes Yes
A51+A52+A53+A54+A55+A56+A57=A58
Yes Yes Yes Yes
A59+A61-A62-A63=A64
Yes Yes Yes Yes
A64+A66+A67=A68
Yes Yes Yes Yes
A74+A75+A76+A77+A78+A79+A80=A45
Yes Yes Yes Yes







Various Edit Checks





R20<=R21
Yes Yes Yes Yes total net patient revenue < or = total operating revenue
R21-R25+H6-H7+R26=R27
Yes Yes Yes Yes tot op rev - tot op exp + non op rev - non op exp - extraordinary items = net income
H4+H5+R22+R23+R24<=R25
Yes Yes Yes Yes tot supplies exp + tot sale & benefits + deep exp + into exp + bad debt exp <= tot op exp
R6+R7+R8<=R9
Yes Yes Yes Yes cash & temp invest + net AR + inventories<= tot currents assets
R9+R10+R12<=R13
Yes Yes Yes Yes tot currents assets + limited use assets + net fixed assets <= tot assets
R13=R17+R18
Yes Yes Yes Yes total assets = total liabilities + unrestricted fund balance
H1+R14<=R15
Yes Yes Yes Yes AP & accrued exp + current portion LT debt <= total liabilities
R!5+R16<=R17
Yes Yes Yes Yes total current lab + LT capital debt = total liabilities







Reasonableness Review for Cost per Discharge
#DIV/0! #DIV/0! #DIV/0! #DIV/0!

Sheet 5: Monthly Reporting - 4th Qtr

FINANCIAL AND STATISTICAL DATA FOR HUD REPORTING
ENTER FYE HERE
ENTER HOSPITAL NAME HERE

If monthly reporting is required enter 1, if quarterly enter 2



Instructions:





(A.) Please call your OIHCF Account Executive for any clarifications.





(B.) For the FY month that you are completing, a value must be entered for all cells highlighted in yellow





(C.) All line items in your financials must be summarized on this worksheet (e.g., if you have a current asset on your balance sheet and there is no





specific line on this worksheet for it, then it should be included in "All Other Current Assets")





(D.) Footnotes, which provide an explanation of some lines, are located on Page 4.



















Description Entry Label 10th Month 11th Month 12th Month Do not Use - Start New Spreadsheet


YTD YTD YTD YTD
Balance Sheet





Cash & Temporary Investments R06




Gross Patient Receivables





Allowance for Doubtful Accounts R32




Net Accounts Receivable R07




All Other Current Assets





Total Current Assets R09




Long Term Investments R33




Limited Use or Desginated Assets R10




Gross Property, Plant & Equipment





Accumulated Depreciation R11




Net Property, Plant & Equipment R12




All Other Non-current Assets





Total Assets R13











Accounts Payable & Accrued Expenses H01




Current Portion of LT Debts R14




All Other Current Liabilities





Total Current Liabilities R15




Long Term Capital Debt R16




All Other Long Term Liabilities





Total Long Term Liabilities





Total Liabilities R17




Unrestricted Fund Balance R18




Temporarily Restricted Fund Balance R39




Restricted Fund Balance R19




Total Net Assets





Total Net Assets + Total Liabilities












Income Statement





Net Inpatient Revenue (1) (6) H02




Net Outpatient Revenue (1) (6) H03




Total Net Patient Revenue (1) R20




All Other Operating Revenue





Total Operating Revenue R21











Salaries & Wages H05




Employee Benefits R36




Total Supplies Expense H04




Depreciation & Amortization Expense R22




Interest Expense R23




Bad Debt Expense (1) R24




All Other Operating Expenses





Total Operating Expense R25




Income from Operations












All Non-Operating Revenue H06




All Non-Operating Expense H07




Extraordinary Items & Income Taxes R26




Net Income R27











Unrecognized Gains/Losses R28




Other Changes in Fund Balance (2) R30




Net Increase/Decrease in Fund Balance












Mortage Reserve Fund





Required MRF Balance H11




Actual MRF Balance H12




Net Inpatient Revenue (1)





Medicare H13




Medicaid H14




Blue Cross H15




Commercial Insurance H16




HMO/Managed Care H17




Self Pay H18




Other H45




Inpatient Utilization





Total Licensed Beds H19




Total Staffed Beds H20




Acute Medical/Surgical Service





Number of Beds H21




Discharges H22




Patient Days H23




Newborn Service





Number of Beds H24




Discharges H25




Patient Days H26




Other Acute Care Services





Number of Beds H27




Discharges H28




Patient Days H29




Other Non-Acute Care





Number of Beds H30




Discharges H31




Patient Days H32




Acute Care Only (Excl. Newborn)





Medicare





Case Mix Index (3) H33




ALOS (5) H34




Non-Medicare





Case Mix Index (3) H35




ALOS (5) H36




All Patients





Case Mix Index (3) H37




ALOS (5) H38




Inpatient Cost per Discharge H39




Outpatient Utilization





Emergency Room Visits H40




Ambulatory Surgery H41




Clinic Visits H42




Other Outpatient Visits H43




Staffing





Total Full-Time Equivalents (4) H44


















Footnotes:





(1) Bad Debt Expense is recorded as a separate line item, not as a component of net patient revenue.





(2) Please provide an explanation for any "Other Changes in Fund Balance".





(3) Please enter using only 2 decimal points





(4) Please enter using only a whole number





(5) Please enter using only 1 decimal point





(6) These are estimates. To estimate the Net Inpatient Revenue, use the percentage of Gross Inpatient Revenue to Gross Total Patient Revenue.



















Edit Checks
Edit Satisfied? Edit Satisfied? Edit Satisfied? Edit Satisfied?
Balance Sheet





A17-A18=A19
Yes Yes Yes Yes
A16+A19+A20=A21
Yes Yes Yes Yes
A21+A22+A23+A26+A27=A28
Yes Yes Yes Yes
A30+A31+A32=A33
Yes Yes Yes Yes
A34+A35=A36
Yes Yes Yes Yes
A33+A36=A37
Yes Yes Yes Yes
A38+A39+A40=A41
Yes Yes Yes Yes
A37+A41=A42
Yes Yes Yes Yes







Income Statement





A45+A46=A47
Yes Yes Yes Yes
A47+A48=A49
Yes Yes Yes Yes
A51+A52+A53+A54+A55+A56+A57=A58
Yes Yes Yes Yes
A59+A61-A62-A63=A64
Yes Yes Yes Yes
A64+A66+A67=A68
Yes Yes Yes Yes
A74+A75+A76+A77+A78+A79+A80=A45
Yes Yes Yes Yes







Various Edit Checks





R20<=R21
Yes Yes Yes Yes total net patient revenue < or = total operating revenue
R21-R25+H6-H7+R26=R27
Yes Yes Yes Yes tot op rev - tot op exp + non op rev - non op exp - extraordinary items = net income
H4+H5+R22+R23+R24<=R25
Yes Yes Yes Yes tot supplies exp + tot sale & benefits + deep exp + into exp + bad debt exp <= tot op exp
R6+R7+R8<=R9
Yes Yes Yes Yes cash & temp invest + net AR + inventories<= tot currents assets
R9+R10+R12<=R13
Yes Yes Yes Yes tot currents assets + limited use assets + net fixed assets <= tot assets
R13=R17+R18
Yes Yes Yes Yes total assets = total liabilities + unrestricted fund balance
H1+R14<=R15
Yes Yes Yes Yes AP & accrued exp + current portion LT debt <= total liabilities
R!5+R16<=R17
Yes Yes Yes Yes total current lab + LT capital debt = total liabilities







Reasonableness Review for Cost per Discharge
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