TITLE 77: PUBLIC HEALTH
CHAPTER X: DEPARTMENT OF HUMAN SERVICES
SUBCHAPTER i: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.APPENDIX B A GUIDE TO COST ANALYSIS DEVELOPING COST BASED FEES AND SLIDING FEE SCALE



Section 635.APPENDIX B   A Guide to Cost Analysis Developing Cost Based Fees and Sliding Fee Scale

 

 

 

 

 

 

 

 

 

 

 

 

Illinois Department of Public Health

 

 

A Guide to Cost Analysis

 

Developing Cost Based Fees

 

and

 

Sliding Fee Scale

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Revised 11/89

A.B.A.


 

 

TABLE OF CONTENTS

 

INTRODUCTION.............................................................................................................................

APPROACH......................................................................................................................................

FUNCTIONAL AREAS.....................................................................................................................

DETERMINATION OF COST PER PROCEDURE............................................................................

PREPARE A COST OF SERVICE/FEE DETERMINATION

WORKSHEET FOR EACH COST CENTER..........................................................................

EXPENSE ALLOCATIONS FOR THE BCRR...................................................................................

RELATIVE VALUES........................................................................................................................

OPTIONAL REVENUE ANALYSIS.................................................................................................

CALCULATING THE SCHEDULE OF DISCOUNTS.......................................................................

DEVELOPMENT OF A SLIDING FEE SCALE.................................................................................

 

ATTACHMENTS

 

ATTACHMENT A:

SAMPLES OF ADMINISTRATIVE COSTS......................................................

ATTACHMENT B:

MEDICAL COST CENTER WORKSHEET.......................................................

ATTACHMENT C:

LABORATORY COST CENTER WORKSHEET..............................................

ATTACHMENT D:

PHARMACY COST CENTER WORKSHEET..................................................

ATTACHMENT E:

EDUCATION/COUNSELING COST CENTER WORKSHEET.........................

ATTACHMENT F:

POVERTY INCOME GUIDELINES – CLIENT FEE DISCOUNT CATEGORIES

ATTACHMENT G:

SLIDING FEE SCALE......................................................................................

 

LIST OF EXAMPLES

 

ALLOCATION OF MONIES FOR BCRR.........................................................................................

COMPLETED BCRR FROM ABOVE ALLOCATIONS....................................................................

DETERMINATION OF COST PER PROCEDURE............................................................................

FEE DETERMINATION WORKSHEETS.........................................................................................

 

Medical...........................................................................................................

 

Laboratory......................................................................................................

 

Pharmacy........................................................................................................

 

Education and Counseling..............................................................................

POVERTY INCOME GUIDELINES – CLIENT FEE DISCOUNT CATEGORIES.............................

SAMPLE SLIDING FEE SCALE.......................................................................................................

 


 

COST BASED FEES

 

INTRODUCTION

 

Federal regulations require that each family planning project have a schedule of fees for the services it provides.  You must develop realistic fees which reflect the cost of operation, yet are competitive to the local market.  There must be a corresponding schedule of discounts which will be used by individuals based on their ability to pay.

 

It is now necessary for family planning providers to concentrate on management plans which will provide them with the information to develop, implement and analyze their efficiency, thus controlling costs.  Only agencies with a sound financial management plan will remain financially viable.

 

The object of this manual is to help you determine the cost of providing services and setting the fees to be charged using Bureau of Community Health Services Common Reporting Requirements (BCRR) data with some modifications and utilization data provided by your CVR's.

 

Costs will come from using the financial information you reported in the various cost centers of your BCRR, Table 6, Column g.  We would suggest completing the expense allocations pages to check the accuracy of your allocations on the BCRR and to insure accurate fees.

 

Utilization figures must be collected over the same period as the reported costs.  Specific procedure data, not encounter data, must be used, since the purpose is to derive a cost per procedure.  An actual count of your procedures over a specific time period may be obtained from your population profile as reported from your CVR's or you may use a daily log of clinic activity.

 

APPROACH

 

Rates charged for each service should reflect both direct and indirect costs.  Direct costs include expenses associated with providing patient care (i.e., physician, nursing, supplies, etc.) plus an amount of overhead or indirect costs which are expended to support direct patient care (i.e., administration, housekeeping, rent, etc.).  In order to arrive at a true cost you must include the value of donated goods and services.  You have allocated your overhead or indirect costs to the various cost centers on Table 6, worksheets A and B (administration, facility costs and fringe benefits) so that the amount on Table 6, column g in each cost center represents your total costs.  Examples of administrative and facility costs are Attachment A.

 

There are seven steps in the development of cost based fee:

 

1.         Identify the functional cost centers.

 

2.         Identify services provided in each cost center.

 

3.         Collect utilization data on services provided.

 

4.         Collect direct cost data for each functional cost center.

 

5.         Allocate overhead costs to functional cost centers.

 

6.         Determine total units of service provided.

 

7.         Determine cost of each service.

 

FUNCTIONAL AREAS

 

The health care functional areas within a family planning program represent a separation of functions within the program.  A typical family planning program will provide services within four functional areas:

 

A.        MEDICAL (CLINIC) OPERATIONS

Medical services delivered in providing a family planning method of a patient, and the diagnosis and treatment of related problems; excludes x-ray, laboratory and pharmacy services.

 

B.        LABORATORY

Laboratory services provided by the family planning program including specimen collection and preparation for referral to outside laboratories.

 

C.        PHARMACY

Services provided in the dispensing of contraceptives and medications to the family planning patient.

 

D.        HEALTH EDUCATION/COUNSELING

Services provided to the client or prospective client for family planning related problem resolution or information.  Includes tubal ligation counseling, fertility awareness and similar services.

 

DETERMINATION OF COST PER PROCEDURE

 

The purpose of this step is to distribute health care costs to particular procedures to derive the unit cost of each procedure.  The cost per procedure should be computed for all procedures.  The cost per procedure information is useful for managers in establishing charges and for analyzing the benefit of continuing to provide specific services.  There may be some cases in which the cost per procedure requires a charge so far above the competitive rate (what other providers in the area would charge for that service) that the charge is prohibitive.  This should be a signal to management that steps must be taken to lower costs in the future or consideration should be given to phasing out that service and making alternative arrangements.

 

In order to determine the cost you must define the specific procedures performed in each cost center and determine how many times or frequency the procedure is performed.  We have assigned relative values to procedures.

 

Prepare a Cost of Service/Fee Determination Worksheet for each cost center.  See Attachment B, C, D and E.

 

MEDICAL COST CENTER

Attachment B

1.

Column A

–

List procedure

2.

Column B

–

List Service Utilization/Frequency of Procedure.

3.

Column C

–

List Relative Value for Procedure.

4.

Column D

–

Column B X Column C. Total Column D.

5.

Column E

–

Cost center amount from BCRR Table 6, Column G, line 1.

6.

Column F

–

Total Column E divided by total Column D. This gives you your average cost/service unit which is listed for each line item.

7.

Column G

–

The dollar amount in Column F times each RVS of Column C. This amount represents the cost for each specific service.

8.

Column H

–

Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH.

9.

Column I

–

Adjusted cost equal's cost/service in Column G times Column H, cost of living allowance (COLA) % plus 100%.

 

 

 

Example:

 

 

 

$10.00 X 105% = $10.50

10.

Column J

–

The full fee to be charged and should approximate Column K. For convenience round up to nearest dollar.

 

LABORATORY COST CENTER

Attachment C

1.

Column A

–

List lab services provided.

2.

Column B

–

List Service Utilization/Frequency of Procedure.

3.

Column C

–

List Relative Value for Procedure.

4.

Column D

 

Column B X Column C. Total Column D.

5.

Column E

–

Cost center amount from BCRR Table 6, Column G, line 2, minus the cost of PURCHASED OUTSIDE LABORATORY TESTS equals adjusted total cost/cost center. OUTSIDE LABORATORY TESTS ARE THOSE TESTS NOT PERFORMED BY THE AGENCY. This does not include collection of specimens.

6.

Column F

–

Total adjusted cost center, Column E, divided by total service units, Column D, equals Column F, the average cost/service unit.

7.

Column G

–

Adjusted cost/service equals the dollar amount in Column F times each relative value of Column C. This amount represents the cost for each specific service. Column F X Column C.

8.

Column H

–

Enter the per unit purchase expense of OUTSIDE LABORATORY TESTS on the appropriate line or lines. This additional purchase expense applies only to designated tests. For nondesignated test, Column H equals ZERO.

9.

Column I

–

Total base cost equals adjusted cost/service plus per unit purchase expenses. Column G + Column H.

10.

Column J

–

Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH.

11.

Column K

–

Adjusted cost equals total base cost in Column I times Column J, cost of living allowance (COLA) % plus 100%.

 

 

 

Example:

 

 

 

$4.60 X 105% = $4.83

12.

Column L

–

The full fee to be charged and should approximate Column K. Cor convenience round up to nearest dollar.

 

PHARMACY COST CENTER

Attachment D

1.

Column A

–

List pharmaceuticals provided.

2.

Column B

–

List Service Utilization.

3.

Column C

–

List Relative Value for Pharmaceuticals.

4.

Column D

–

Column B X Column C. Total Column D.

5.

Column E

–

Cost center amount from BCRR Table 6, Column G, line 4, minus the cost of consumed pharmaceuticals equals adjusted total cost/cost center.

6.

Column F

–

Total adjusted cost center, Column E, divided by total service units, Column D, equals Column F, the average cost/service unit.

7.

Column G

–

Adjusted cost/service equals the dollar amount in Column F, times each relative value of Column C. This amount represents the cost for each specific service. Column F x Column C.

8.

Column H

–

Equals the purchase expense per pharmaceutical unit. To arrive at an average per unit purchase expense, for Attachment D, Column H, when several brands of a pharmaceutical are purchased at different prices you will divide the total dollar value of those pharmaceuticals consumed during that period by the total number of units of those pharmaceuticals consumed during the same reporting period.

9.

Column I

–

Total base cost equals adjusted cost/service plus per unit purchase expense. Column G + Column H.

10.

Column J

–

Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH.

11.

Column K

–

Adjusted cost equals total base cost in Column I times Column J, cost of living allowance (COLA) % plus 100%.

 

 

 

Example:

 

 

 

$4.60 X 105% = $4.83

12.

Column L

–

The full fee to be charged and should approximate Column K. For convenience round up to nearest dollar.

 

EDUCATION/COUNSELING COST CENTER

Attachment E

1.

Column A

–

List procedure.

2.

Column B

–

List Service Utilization/Frequency of Procedure.

3.

Column C

–

List Relative Value for Procedure.

4.

Column D

–

Column B X Column C. Total Column D.

5.

Column E

–

Cost center amount from BCRR, Table 6, Column G, line 7.

6.

Column F

–

Total Column E divided by total Column D. This gives you your average cost/service unit which is listed for each line item.

7.

Column G

–

The dollar amount in Column F times each RVS of Column C. This amount represents the cost for each specific service.

8.

Column H

–

Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH.

9.

Column I

–

Adjusted cost equals cost/service in Column G times Column H, cost of living allowance (COLA)% plus 100%.

 

 

 

Example:

 

 

 

$10.00 X 105% = $10.50

10.

Column J

 

The full fee to be charged and should approximate Column K.  For convenience round up to nearest dollar.

 

MEDICAL COST CENTER

CLIENT EXAMINATION DIRECT EXPENSES SALARIES AND WAGES

(Include only those staff who perform or assist in performing client examinations.)

 

 

1.

Physician

1.

$

.00

 

2.

Physician Assistants

2.

$

.00

 

3.

Nurse Practitioners

3.

$

.00

 

4.

Nurse Midwives

4.

$

.00

 

5.

Other Nurses

5.

$

.00

MEDICAL SUPPORT

 

6.

Medical Appointment Secretary

6.

$

.00

 

7.

Portion of Client Records Clerk

7.

$

.00

 

8.

Total Salaries

8.

$

.00

 

 

Total on line 8 is equal to BCRR Table 6, worksheet A, column E, line 1.

 

 

 

OTHER CLIENT EXAMINATION EXPENSES

 

9.

Contractual Examiners Fees

9.

$

.00

 

10.

Client Examination Equipment Lease or Rental

10.

$

.00

 

11.

Client Examination Equipment Depreciation

11.

$

.00

 

12.

Client Examination Equipment Depreciation Expense

12.

$

.00

 

13.

Client Examination Supplies Expense

13.

$

.00

 

14.

Client Examination Staff Travel Expense

14.

$

.00

 

15.

Malpractice Insurance

15.

$

.00

 

16.

Other Client Examination Expenses

16.

$

.00

 

17.

Total Other Client Examination Expenses

17.

$

.00

 

 

(Sum of lines 9 through 16)

Total on line 17 is equal to BCRR Table 6, worksheet A, Column I, line 1.

 

 

 

DONATED MEDICAL EXPENSES

 

18.

Value of Physician's Donated Time

18.

$

.00

 

19.

Value of Nurse Midwife/N.P.'s Donated Time

19.

$

.00

 

20.

Value of R.N.'s Donated Time

20.

$

.00

 

21.

Value of LPN's Donated Time

21.

$

.00

 

22.

Value of other Donated Medical Expenses

22.

$

.00

 

23.

Total Donated Services and Materials

23.

$

.00

 

 

(Sum of lines 18 through 22)

Total on line 23 is equal to BCRR Table 6, worksheet A, Column j, line 1.

 

 

 

PATIENT EXAM INDIRECT COSTS

 

24.

Medical Fringe Benefits

24.

$

.00

 

 

(Worksheet A – Column g, line 1)

 

 

 

 

25.

Medical Facility Costs

25.

$

.00

 

 

(Worksheet B – Column d, line 1)

 

 

 

 

26.

Administrative Costs

26.

$

.00

 

 

(Worksheet B – Column g, line 1)

 

 

 

To arrive at the total medical costs you will add salary and wages (8), other costs (17) and donated services and materials (23) to the fringe benefits (24), facility costs (25) and administrative costs (26).

 

27.

Total Medical Costs

27.

$

.00

 

 

This total equals BCRR Table 6, Column g, line 1.

 

 

 

 

 

 

LABORATORY COST CENTER

LABORATORY SERVICES DIRECT EXPENSES

 

28.

Salaries and Wages (include only those staff who

 

 

 

 

 

perform tests, assist in tests or prepare specimens)

28.

$

.00

 

29.

Total

29.

$

.00

 

 

Total on line 29 is equal to BCRR Table 6, worksheet A, Column E, line 2.

 

 

 

OTHER LABORATORY EXPENSES

 

30.

Laboratory Equipment Lease or Rental Expense

30.

$

.00

 

31.

Laboratory Equipment Depreciation Expense

31.

$

.00

 

32.

Laboratory Equipment Maintenance and Repair Expense

32.

$

.00

 

33.

Laboratory Supplies Expense

33.

$

.00

 

34.

Purchased Outside Laboratory Services Expense

34.

$

.00

 

35.

Other Laboratory Expenses

35.

$

.00

 

36.

Total Other Laboratory Services Direct Expenses

36.

$

.00

 

 

(Sum of lines 30 through 35)

Total on line 36 is equal to BCRR Table 6, worksheet A, Column I, line 2.

 

 

 

DONATED LABORATORY EXPENSES

 

37.

Value of Lab Technician's Donated Time

37.

$

.00

 

38.

Value of Donated Lab Supplies

38.

$

.00

 

39.

Value of Donated Lab Tests

39.

$

.00

 

40.

Value of other Donated Lab Expenses

40.

$

.00

 

41.

Total Donated Laboratory Services and Materials

41.

$

.00

 

 

(Sum of lines 37 through 40)

Total on line 41 is equal to BCRR Table 6, worksheet A, Column j, line 2.

 

 

 

LABORATORY SERVICES INDIRECT EXPENSES

 

42.

Laboratory Fringe Benefits

42.

$

.00

 

 

(Worksheet A – Column g, line 2)

 

 

 

 

43.

Laboratory Facility Costs

43.

$

.00

 

 

(Worksheet B – Column d, line 2)

 

 

 

 

44.

Laboratory Administration Costs

44.

$

.00

 

 

(Worksheet B – Column g, line 2)

 

 

 

To arrive at the total laboratory expenses you will add salary and wages (29), other costs (36) and donated services and materials (41) to the fringe benefits (42), facility costs (43) and administrative costs (44).

 

45.

Total Laboratory Costs

45.

$

.00

 

 

This total equals BCRR Table 6, Column g, line 2.

 

 

 

OUTSIDE LABORATORY TESTS:

Any laboratory test completed by an outside incorporated entity.  An invoice and payment to the entity for services must exist.

If you have "purchased outside laboratory fees" which will be included in total laboratory expenses for you BCRR information, you must now subtract the dollar amount of those purchases from your BCRR total on Table 6, Column G, line 2 to arrive at the dollar amount to be used in your total adjusted cost/center of Attachment C, Column E.  You WILL NOT use the amount from you BCRR Table 6, Column G, line 2 for this amount.

 

OUTSIDE LABORATORY COST AREA

 

Type of Supply

Your Cost/Unit x Number Used = Total Expense*

 

46.

VDRL/RPR

$

x

 

$

.00

 

47.

Pap Smear

$

x

47.

$

.00

 

48.

Gonorrhea Culture

$

x

48.

$

.00

 

49.

Miscellaneous Culture

$

x

49.

$

.00

 

50.

Sickle Cell

$

x

50.

$

.00

 

51.

PP Blood Glucose

$

x

51.

$

.00

 

52.

Cholesterol Level

$

x

52.

$

.00

 

53.

SMA 12

$

x

53.

$

.00

 

54.

Colposcopy

$

x

54.

$

.00

 

55.

Colposcopy and Biopsy

$

x

55.

$

.00

 

56.

Chlamydia

$

x

56.

$

.00

 

57.

Total Outside Laboratory Fees

 

 

57.

$

.00

 

*Round to the nearest dollar amount.

 

58.

Adjusted total cost/center:

 

 

58.

$

.00

 

 

Line 45, subtract Line 67, equals amount on Line 58. This is the amount to be used in the Adjusted Total Cost/Center, Attachment C, Column E.

 

 

 

 

 

 

PHARMACY COST CENTER

Supplies Consumed During Reporting Period:

Type of Supply

Your Cost/Unit x *Number Used = Total Expense*

 

59.

Oral Contraceptives

 

x

59.

$

.00

 

60.

Cream

 

x

60.

$

.00

 

61.

Jelly

 

x

61.

$

.00

 

62.

Suppository (each)

 

x

62.

$

.00

 

63.

Foam

 

x

63.

$

.00

 

64.

Diaphragm

 

x

64.

$

.00

 

65.

IUD

 

x

65.

$

.00

 

66.

Basal T & C

 

x

66.

$

.00

 

67.

Sponges (each)

 

x

67.

$

.00

 

68.

Condoms (each)

 

x

68.

$

.00

 

69.

Meds/Vag. Inf.

 

x

69.

$

.00

 

70.

Meds/Std Rx

 

x

70.

$

.00

 

71.

Contraceptive Film

 

x

71.

$

.00

*The number used for each type of supply will come from your inventory sheets.

 

72.

Total (Sum of lines 59 through 71)

 

 

72.

$

.00

PROVISION OF CONTGRACEPTIVE DRUGS/SUPPLIES DIRECT EXPENSES

 

73.

Salaries and Wages for Staff Who Dispense or

 

 

 

 

 

 

Assist in Providing Contraceptive Drugs and Supplies

 

73.

$

.00

 

74.

Total

 

 

74.

$

.00

 

 

Total on line 74 is equal to BCRR Table 6, worksheet A, Column E, line 4.

 

 

 

 

OTHER PHARMACY EXPENSES

 

75.

Provision of Drugs and Supplies Equipment

 

 

 

 

 

 

Lease or Rental Expense

 

 

75.

$

.00

 

76.

Provision of Drugs and Supplies Depreciation Expense

 

76.

$

.00

 

77.

Provision of Drugs and Supplies Equipment Maintenance and Repair Expense

 

77.

$

.00

 

78.

Dispensing Supplies Expense

 

 

78.

$

.00

 

79.

Other Pharmacy Expenses

 

 

79.

$

.00

 

80.

Total (Sum of lines 75 through 79)

 

 

80.

$

.00

 

81.

Total All Pharmacy Expenses

 

 

81.

$

.00

 

 

(Sum of lines 72 and 80)

Total on line 81 is equal to BCRR Table 6, worksheet A, Column I, line 4.

 

 

 

 

DONATED PHARMACY EXPENSES

 

82.

Value of Pharmacists' Donated Time

 

82.

$

.00

 

83.

Value of Donated Pharmacy Supplies

 

83.

$

.00

 

84.

Value of Donated Contraceptive Supplies

 

84.

$

.00

 

85.

Value of Other Donated Pharmacy Expenses

 

85.

$

.00

 

86.

Total Donated Pharmacy Services and Materials

 

86.

$

.00

 

 

(Sum of lines 82 through 85)

Total on line 86 is equal to BCRR Table 6, worksheet A, Column j, line 4.

 

 

 

 

PHARMACY SERVICES INDIRECT EXPENSES

 

87.

Pharmacy Fringe Benefits

 

87.

$

.00

 

 

(Worksheet A – Column g, line 4)

 

 

 

 

 

88.

Pharmacy Facility Costs

 

 

88.

$

.00

 

 

(Worksheet B – Column d, line 4)

 

 

 

 

 

89.

Pharmacy Administration Costs

 

89.

$

.00

 

 

(Worksheet B – Column g, line 4)

 

 

 

 

To arrive at the total Pharmacy costs you will add salary and wages (74), other costs (81) and donated services and materials (86) to fringe benefits (87), facility costs (88) and administrative costs (89).

 

90

Total Pharmacy Costs

 

90.

$

.00

 

 

This total equals BCRR Table 6, Column g, line 4.

 

 

 

 

 

91.

Adjusted total cost center

 

91.

$

.00

To arrive at the total adjusted cost/center you must subtract the dollar amount of consumed contraceptives, drugs/supplies, from you BCRR total on Table 6, Column G, line 4, which is the amount on Line 90, minus line 72, equals the amount on line 91.  This is the amount to be used in the adjusted Total cost/center, Attachment D, Column E.

 

COUNSELING AND EDUCATION COST CENTER

FAMILY PLANNING COUNSELING AND EDUCATIONAL DIRECT EXPENSES

 

92.

Salaries and Wages, Family Planning

 

92.

$

.00

 

 

Counselors, Educators and Assistants

 

 

 

 

 

93.

Portion of Client Records Clerk

 

93.

$

.00

 

94.

Total

 

94.

$

.00

 

 

Total on line 94 is equal to BCRR Table t, worksheet A, Column E, line 7.

 

 

 

 

OTHER COUNSELING AND EDUCATION EXPENSES

 

95.

Counseling and Educational Services

 

95.

$

.00

 

 

Staff Travel Expense

 

 

 

 

 

 

96.

Counseling and Educational Services

 

96.

$

.00

 

 

Equipment Rental

 

 

 

 

 

 

97.

Counseling Expense or Lease Expense and

 

97.

$

.00

 

 

Educational Services Equipment Depreciation

 

 

 

 

 

98.

Counseling and Educational Services Equipment

98.

$

.00

 

 

Repair and Maintenance Expense

 

 

 

 

 

 

99.

Counseling and Educational Supplies Expense

 

99.

$

.00

 

100.

Other Counseling and Educational Expense

 

100.

$

.00

 

101.

Total Family Planning Counseling and Educational Services Direct Expenses

101.

$

.00

 

 

Total on line 101 is equal to BCRR Table 6, worksheet A, Column I, line 7.

 

 

 

DONATED EDUCATION AND COUNSELING EXPENSES

 

102.

Value of Counselors Donated Time

 

102.

$

.00

 

103.

Value of Other Donated Counseling and Educational Services Expenses

103.

$

.00

 

104.

Total Donated Counseling and Educational Services Expenses

104.

$

.00

 

 

(Sum of lines 102 and 103)

Total on line 104 is equal to BCRR Table 6, worksheet A, Column j, line 7.

 

 

 

 

COUNSELING AND EDUCATIONAL INDIRECT EXPENSES

 

105.

Counseling and Education Fringe Benefits

105.

$

.00

 

 

(Worksheet A – Column g, line 7)

 

 

 

 

 

 

106.

Counseling and Education Facility Costs

106.

$

.00

 

 

(Worksheet B – Column d, line 7)

 

 

 

 

 

 

107.

Counseling and Education Administration Costs

107.

$

.00

 

 

(Worksheet B – Column g, line 7)

 

 

 

 

 

To arrive at the total Counseling and Education costs you will add salary and wages (92), other costs (101) and Donated Counseling and Educational Services (104) to fringe benefits (105), facility costs (106) and administrative costs (107).

 

108.

Total Counseling and Education Costs

108.

$

.00

 

 

This total equals BCRR Table 6, Column g, line 7.

 

 

 

 

 

FAMILY PLANNING CLIENT VISIT RELATIVE VALUES

 

SERVICES

RVS

MEDICAL SERVICES VISITS

 

Minimal Service

11.00

Brief/Intermediate Exam

18.00

Extended Exam

30.00

Insertion of IUD

30.00

Diaphragm Fit

15.00

Sonography/lost IUD

30.00

X-ray/lost IUD

24.00

LAB PROCEDURES

 

Hematocrit/Hemoglobin

3.00

U/A Dip Stick

4.00

Pregnancy Test

10.00

VDRL/RPR

6.00

Pap Smear

8.00

Gonorrhea Culture

6.00

Bacterial Smear/Wet Mount

5.00

Miscellaneous Culture

6.00

Sickle Cell

5.00

P.P. Blood Glucose

6.00

Triglycerides

6.00

SMA 12

16.00

Colposcopy

30.00

Colposcopy with Biopsy

40.00

Chlamydia

7.00

Miscellaneous Culture

3.00

Sickle Cell

4.00

P.P. Blood Glucose

10.00

Triglycerides

6.00

SMA 12

8.00

Colposcopy

6.00

Colposcopy with Biopsy

5.00

Chlamydia

6.00

CONTRACEPTIVE DRUGS/SUPPLIES

 

Orals

1.20

Creams

2.65

Jellies

2.65

Suppositories (each)

.15

Foams

3.00

Diaphragm

4.00

Basal T & C

10.00

IUD

50.00

Sponges (each)

1.50

Condoms (each)

.22

Meds/Vag. Inf.

5.00

Meds/STD

5.00

Contraceptive Film

2.00

EDUCATION AND COUNSELING

In-depth/1 hour

11.00

15 min. to 1 Hour

7.00

 

 

Revised

11/89

 

CALCULATING THE SCHEDULE OF DISCOUNTS

 

1.

Determine the number of payment categories.

 

Example:

For the purpose of this manual, we will use a six step schedule.

 

2.

The income levels for the zero pay category will be the poverty levels published annually in the Federal Register. (See Attachment F)

 

Example:

The poverty level for a one person family is $5,980; for a two person family the poverty level is $8,020, etc.

 

3.

The income levels for the full fee will be 250% of the poverty level plus $1.00.

 

Example:

For Family Size of 1, 100% pay = $5,980 x  2.5 = t$14,950 + $1 or $14,951

 

4.

To determine the income levels between 0% pay and 250% pay, use the following formula:

 

The 250% income level minus the poverty level, divided by the number of payment categories, minus 2.

 

The result of this computation is the dollar range for each step.

 

Example:

Family Size 1 - $14,950 (full fee > 250%) minus $5,980 (0%) = $8,970 divided by 4 (6 steps–2 steps) = $2,242.50 step interval.

 

5.

The lower limit of each step is $1 more than the upper limit of the preceding step.

 

Example:

Family Size 1, upper limit of 0% pay is $5,980, lower limit of the next category (20%) is $5,981.

 

6.

The upper level for each step is computed by adding the dollar interval computed in Step 4 to the upper limit of the preceding step.

 

Example:

Family Size 1 – upper limit of 0% pay is $5,980; upper limit of the next category is $5,981 + $2,243 or $8,224. See Attachment F.

 

 

DEVELOPMENT OF A SLIDING FEE SCALE

 

Federal regulations require that we provide family planning services on a sliding fee scale to allow persons to receive services regardless of their income level and subsequent ability to pay.  Client or family income level is the determining factor for what level or percentage of the full fee a client will be charged.

 

A fee system must be developed and reevaluated at least annually after completing a cost analysis.  The sliding fee scale will be based on the most current Federal Poverty Income Guidelines (See Attachment F).  All clients must update their financial status every 12 months.

 

A sliding fee scale must be simple to be useful.  Any fee scale which is over burdensome to the cashier or person computing the fee loses its value as the time required to compute the fee increases.  Fees must be reasonable, related to cost and not provide a barrier to care.  In selecting the client fee discount categories, it is important to remember that too few categories may either classify many clients at the lower end, reducing income, or at the upper end, discouraging clients to seek care because of the cost, thereby also reducing income.  Too many categories may be difficult to implement and administer.  For the purpose of this manual, we will use a six step sliding fee scale.  See Attachment G.

 

Attachment A

EXAMPLES OF ADMINISTRATIVE COSTS

1.

Project Director

2.

Administrative Secretary and Receptionist

3.

Bookkeeper

4.

Administrative supplies

5.

Administrative staff travel and per diem

6.

Vehicle rental or lease expense

7.

Auditing and accounting

8.

Legal fees

9.

Consultants expense

10.

Dues and subscriptions

11.

Advertising

12.

Postage

13.

Printing

14.

Purchased staff training

15.

Fidelity bonding

16.

Photo copy

17.

Equipment depreciation

 

EXAMPLES OF FACILITY COSTS

1.

Custodian or Janitorial Contractual Services

2.

Building rental

3.

Building depreciation

4.

Building and contents insurance

5.

Building maintenance and repair

6.

Security

7.

Utilities

8.

Telephone

9.

Janitorial supplies

 


 

Attachment B

COST OF SERVICE/FEE DETERMINATION WORKSHEET

MEDICAL

COST CENTER

 

(A)

 

SERVICE/PROCEDURE

 

(B)

 

SERVICE

UTILIZATION

(FREQUENCY)

 

(C)

 

RVS

VALUE

 

(D)

 

TOTAL

SERVICE

UNITS

 

(E)

 

TOTAL

COST/

COST/CENTER

 

(F)

 

AVERAGE

COST/SERVICE

UNIT

 

(G)

 

COST/

SERVICE

 

(H)

 

COST

OF LIVING

ALLOWANCE

 

(I)

 

ADJUSTED

COST

 

(J)

 

FEE

Minimal Service

 

11.00

 

////////////////////////////

 

 

 

 

 

Brief/Intermediate Exam

 

18.00

 

////////////////////////////

 

 

 

 

 

Extended Exam

 

30.00

 

////////////////////////////

 

 

 

 

 

IUD Insertion

 

30.00

 

////////////////////////////

 

 

 

 

 

Diaphragm Fit

 

15.00

 

////////////////////////////

 

 

 

 

 

Sonography/lost IUD

 

30.00

 

////////////////////////////

 

 

 

 

 

X-ray/lost IUD

 

24.00

 

////////////////////////////

 

 

 

 

 

 

 

 

 

////////////////////////////

 

 

 

 

 

 

 

 

 

////////////////////////////

 

 

 

 

 

 

 

 

 

////////////////////////////

 

 

 

 

 

 

 

 

 

////////////////////////////

 

 

 

 

 

 

 

 

 

////////////////////////////

 

 

 

 

 

 

 

 

 

////////////////////////////

 

 

 

 

 

 

 

 

 

////////////////////////////

 

 

 

 

 

 

 

 

 

////////////////////////////

 

 

 

 

 

TOTAL

//////////////////////////

////////////////

 

 

//////////////////////////////

///////////////////

/////////////////////////////////

/////////////////////////

///////////////////////////////////

NOTES

1.

D = B x C

5.

G = F x C

 

REVISED

03-NOV-89

 

2.

Total Column D

6.

M = Cost of Living Allowance (COLA)

3.

E = Column G, line 1 of BCRR Table 6

7.

I = G x (COLA % + 100%)

4.

F = Column E χ Column D Total

8.

J = Fee

 


 


Attachment C

 

COST OF SERVICE/FEE DETERMINATION WORKSHEET

LABORATORY

COST CENTER

 

(A)

 

SERVICE/PROCEDURE

 

(B)

 

SERVICE

UTILIZATION

(FREQUENCY)

 

(C)

 

RVS

VALUE

 

(D)

 

TOTAL

SERVICE

UNITS

 

(E)

 

ADJUSTED

TOTAL COST/

COST/CENTER

 

(F)

 

AVERAGE

COST/SERVICE

UNIT

 

(G)

 

COST/

SERVICE

ADJUSTED

 

(H)

 

PER UNIT

PURCHASE

EXPENSE

 

(I)

 

TOTAL

BASE

COST

 

(J)

 

COST OF

LIVING

ALLLOWANCE

 

(K)

 

ADJUSTED

COST

 

(L)

 

FEE

HGB/HCT

 

3.00

 

//////////////////////////

 

 

 

 

 

 

 

Urinalysis

 

4.00

 

///////////////////////////

 

 

 

 

 

 

 

Pregnancy Test

 

10.00

 

////////////////////////////

 

 

 

 

 

 

 

VDRL/RPR

 

6.00

 

///////////////////////////

 

 

 

 

 

 

 

Pap Smear

 

8.00

 

///////////////////////////

 

 

 

 

 

 

 

Gonorrhea Culture

 

6.00

 

///////////////////////////

 

 

 

 

 

 

 

Miscellaneous Culture

 

6.00

 

//////////////////////////

 

 

 

 

 

 

 

Bacterial Smear/Wet Mount

 

5.00

 

//////////////////////////

 

 

 

 

 

 

 

Sickle Cell

 

5.00

 

//////////////////////////

 

 

 

 

 

 

 

P.P. Blood Glucose

 

6.00

 

//////////////////////////

 

 

 

 

 

 

 

Cholesterol Level

 

6.00

 

//////////////////////////

 

 

 

 

 

 

 

SMA – 12

 

16.00

 

//////////////////////////

 

 

 

 

 

 

 

Colposcopy

 

30.00

 

//////////////////////////

 

 

 

 

 

 

 

Colposcopy and Biopsy

 

40.00

 

//////////////////////////

 

 

 

 

 

 

 

Chlamydia

 

7.00

 

//////////////////////////

 

 

 

 

 

 

 

TOTAL

/////////////////////////

////////////////

 

 

////////////////////////

///////////////////

/////////////////////////

//////////////////

////////////////////

////////////////

/////////////////

NOTES:

1.

D = B x C

6.

H = Actual Per Unit Purchase Expense From Outside Laboratory

REVISED

03-NOV-89

 

2.

Total Column D

7.

I = Total Cost G + H

3.

E = Column G, line 2 of BCRR Table 6,

8.

J = Cost of Living Allowance (COLA)

 

Minus the Cost of Purchased Outside Laboratory Tests

9.

K = I x (COLA % + 100%)

4.

F = Column E χ Column D Total

10.

L = Fee

5.

G = F x C

 

 


 

Attachment D

 

COST OF SERVICE/FEE DETERMINATION WORKSHEET

 

PHARMACY

COST CENTER

 

(A)a

 

SERVICE/PROCEDURE

 

(B)

 

SERVICE

UTILIZATION

(FREQUENCY)

 

(C)

 

RVS

VALUE

 

(D)

 

TOTAL

SERVICE

UNITS

 

(E)

 

ADJUSTED

TOTAL COST/

COST/CENTER

 

(F)

 

AVERAGE

COST/SERVICE

UNIT

 

(G)

 

COST/

SERVICE

ADJUSTED

 

(H)

 

PER UNIT

PURCHASE

EXPENSE

 

(I)

 

TOTAL

BASE

COST

 

(J)

 

COST OF

LIVING

ALLOWANCE

 

(K)

 

ADJUSTED

COST

 

(L)

 

FEE

Orals

 

1.20

 

//////////////////////

 

 

 

 

 

 

 

Creams

 

2.65

 

//////////////////////

 

 

 

 

 

 

 

Jellies

 

2.65

 

///////////////////////

 

 

 

 

 

 

 

Suppositories (each)

 

0.15

 

///////////////////////

 

 

 

 

 

 

 

Foams

 

3.00

 

///////////////////////

 

 

 

 

 

 

 

Diaphragms

 

4.00

 

///////////////////////

 

 

 

 

 

 

 

IUDS

 

50.00

 

///////////////////////

 

 

 

 

 

 

 

Basal T & C

 

10.00

 

///////////////////////

 

 

 

 

 

 

 

Sponges (each)

 

1.50

 

///////////////////////

 

 

 

 

 

 

 

Condoms (each)

 

0.22

 

///////////////////////

 

 

 

 

 

 

 

Meds/Vag Inf

 

5.00

 

///////////////////////

 

 

 

 

 

 

 

Meds/STD

 

5.00

 

///////////////////////

 

 

 

 

 

 

 

Contraceptive Film

 

2.00

 

///////////////////////

 

 

 

 

 

 

 

 

 

 

 

///////////////////////

 

 

 

 

 

 

 

 

 

 

 

///////////////////////

 

 

 

 

 

 

 

TOTAL

/////////////////////////

//////////////

 

 

////////////////////////

//////////////////////

////////////////////

////////////////

/////////////////////

////////////////////

//////////////////////

NOTES:

1.

D =  B x C

6.

H = Actual Per Unit Purchase Expense

 

REVISED

 

2.

Total Column D

7.

I = G + H

 

03-NOV-89

3.

E = Column G, line 4 of BCRR Table 6

8.

J = Cost of Living Allowance (COLA)

 

 

Minus the Cost of Consumed Pharmaceuticals

9.

K x (COLA % + 100%)

4.

F = Column E χ Column D Total

10.

L = Fee

5.

G = F x C

 

 


 

Attachment E

 

COST OF SERVICE/FEE DETERMINATION WORKSHEET

EDUCATION/COUNSELING

COST CENTER

 

(A)

 

SERVIC/PROCEDURE

 

(B)

 

SERVICE

UTILIZATION

(FREQUENCY)

 

(C)

 

RVS

VLAUE

 

(D)

 

TOTAL

SERVICE

UNITS

 

(E)

 

TOTAL

COST/

COST/CENTER

 

(F)

 

AVERAGE

COST/SERVICE

UNIT

 

(G)

 

COST/

SERVICE

(

H)

 

COST OF

LIVING

ALLOWANCE

 

(I)

 

ADJUSTED

COST

 

(J)

 

FEE

Indepth 1 Hour

 

11.00

 

///////////////////

 

 

 

 

 

Counseling/15 Min to 1 Hr

 

7.00

 

///////////////////

 

 

 

 

 

 

 

 

 

///////////////////

 

 

 

 

 

 

 

 

 

///////////////////

 

 

 

 

 

 

 

 

 

///////////////////

 

 

 

 

 

 

 

 

 

///////////////////

 

 

 

 

 

 

 

 

 

///////////////////

 

 

 

 

 

 

 

 

 

///////////////////

 

 

 

 

 

 

 

 

 

///////////////////

 

 

 

 

 

 

 

 

 

///////////////////

 

 

 

 

 

 

 

 

 

///////////////////

 

 

 

 

 

 

 

 

 

///////////////////

 

 

 

 

 

 

 

 

 

///////////////////

 

 

 

 

 

 

 

 

 

///////////////////

 

 

 

 

 

 

 

 

 

///////////////////

 

 

 

 

 

TOTAL

////////////////////

///////////////

 

 

////////////////////

//////////////

//////////////////

/////////////////

//////////////

 

 

 

 

 

 

 

NOTES:

1.

D = B x C

5.

G = F x C

 

REVISED

03-NOV-89

 

2.

Total Column D

6.

H = Cost of Living Allowance (COLA)

3.

E = Column G, line 7 of BCRR Table 6

7.

I = G x (COLA % + 100%)

4.

F = Column E χ Column D Total

8.

J = Fee

 


 

Attachment F

EXAMPLE

POVERTY INCOME GUIDELINES

CLIENT FEE DISCOUNT CATEGORIES

03/08/89

Family Planning Services

1989 Revised Guidelines as published in Federal Register, 2/16/89, Vol. 54, No. 31

 

FAMILY

SIZE

 

0%

 

 

20%

 

 

40%

 

 

60%

 

 

80%

 

100%

A

 

B

C

 

D

E

 

F

G

 

H

I

 

J

K

1

0

–

5980

5981

–

8224

8225

–

10467

10468

–

12711

12712

–

14950

14951

2

0

–

8020

8021

–

11029

11030

–

14037

14038

–

17046

17047

–

20050

20051

3

0

–

10060

10061

–

13834

13835

–

17607

17608

–

21381

21382

–

25150

25151

4

0

–

12100

12101

–

16639

16640

–

21177

21178

–

25716

25717

–

30250

30251

5

0

–

14140

14141

–

19444

19445

–

24747

24748

–

30051

30052

–

35350

35351

6

0

–

16180

16181

–

22249

22250

–

28317

28318

–

34386

34387

–

40450

40451

7

0

–

18220

18221

–

25054

25055

–

31887

31888

–

38721

38722

–

45550

45551

8

0

–

20260

20261

–

27859

27860

–

35457

35458

–

43056

43057

–

50650

50651

*

FOR FAMILY UNITS WITH MORE THAN 8 MEMBERS, FOR EACH ADDITIONAL MEMBER AND ADD TO COLUMN B; $2,040

**

POVERTY LEVEL

$5,980

 

B

=

Family size = 1 =  Poverty Level

B

=

All other Family size = Previous Family size Poverty Level plus $2,040

C

=

(B + 1)

D

 

(J – B) / 4 + C

E

 

(D + 1)

F

=

(J–B) / 4 + E

G

=

(F + 1)

H

=

(J–B) / 4 + G

I

=

(H + 1)

J

=

(B x 2.5)

K

=

(J + 1)

 


 

Attachment G

SLIDING FEE SCALE

**********************************************************************************************************************

SERVICE/PROCEDURES

(a)

COST/

SERVICES

 

FEE

 

0%

 

20%

 

40%

 

60%

 

80%

 

100%

Minimal Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Brief/Intermediate Exam

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Extended Exam

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IUD Insertion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diaphragm Fit

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sonography/lost IUD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

X-ray/lost IUD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HCT/HBG

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Urinalysis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pregnancy Test

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VDRL/RPR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pap Smear

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gonorrhea Culture

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Miscellaneous Culture

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bacterial Smear/Wet Mount

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sickle Cell

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PP Blood Glucose

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cholesterol Level

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SMA-12

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Colposcopy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Colposcopy and Biopsy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chlamydia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Orals

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Creams

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Jellies

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Suppositories (each)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Foams

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diaphragms

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IUDS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Basal T & C

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sponges (each)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Condoms (each)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Meds/Vag Inf

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Meds/STD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contraceptive Film

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In-depth 1 Hour

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Counseling/15 Min. to 1 Hr.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**********************************************************************************************************************

 


 

ALLOCATION OF MONIES FOR BCRR

SALARIES

EQUIPMENT DEPRECIATION

 

0.5

OB/GYN Physician

50,000

 

Medical

800

2.0

OB/GYN Nurse Practitioners

52,000

 

Laboratory

200

1.5

RN’s

24,000

 

Patient Records

100

0.5

RN (Pharmacy)

8,000

 

Administration

900

2.0

LPN’s

22,000

 

0.5

Medical Appt. Secy.

5,750

0.5

Client Records Clerk

5,750

 

INSURANCE

1.0

Health Educator

16,000

 

0.5

Laboratory Technician

7,000

 

Medical Malpractice

5,000

1.0

Project Director

20,000

 

Fidelity Bonding

100

1.0

Admin. Secy./Recept.

12,000

 

Facility (fire, flood)

1,000

1.0

Bookkeeper

12,000

 

 

 

0.2

Custodian

1,600

 

 

 

 

RENT

12,000

UTILITIES

1,800

TELEPHONE

740

FRINGE BENEFITS

27,300

 

PHOTO COPY

560

 

POSTAGE

375

 

ADMIN. TRAVEL

200

CONSULTANT & CONTRACT SERVICES

 

Nurse Practitioner

17,000

 

SQUARE FOOTAGE

 

Outside Laboratory

19,792

 

 

 

Account’s Fee

800

 

Medical

1,600 sq'

Attorney’s Fee

100

 

Laboratory

200

Security

2,000

 

Other Health

300

 

Administration

400

 

2,500 sq'

 

SUPPLIES

 

Medical

10,000

 

Laboratory

3,000

Health Education

500

Pharmacy

1,000

Patient Records

200

Administration

500

Housekeeping

100

 

DONATED MATERIALS

 

Volunteer R.N.’s

6,000

 

GC’s done by State lab

1,200

Contraceptives from closing clinic

2,400

Volunteer Counselor

400

Administrator’s time

700

Rent at 2nd site

1,200

 


 

MEDICAL COST CENTER

CLIENT EXAMINATION DIRECT EXPENSES

SALARIES AND WAGES (Include only those staff who perform or assist in performing client examinations.)

1.

Physician

1.

$

50,000.00

2.

Physician Assistants

2.

$

.00

3.

Nurse Practitioners

3.

$

52,000.00

4.

Nurse Midwives

4.

$

.00

5.

Other Nurses

5.

$

46,000.00

Medical Support

6.

Medical Appointment Secretary

6.

$

5,750.00

7.

Portion of Client Records Clerk

7.

$

4,600.00

8.

Total Salaries

8.

$

158,350.00

 

Total on line 8 is equal to BCRR Table 6,

 

worksheet A, Column E, line 1.

OTHER CLIENT EXAMINATION EXPENSES

9.

Contractual Examiners Fee

9.

$

17,000.00

10.

Client Examination Equipment Lease or Rental

10.

$

.00

11.

Client Examination Equipment Depreciation Expense

11.

$

800.00

12.

Client Examination Equipment Repair & Maintenance

12.

$

.00

13.

Client Examination Supplies Expense

13.

$

10,000.00

14.

Client Examination Staff Travel Expense

14.

$

.00

15.

Malpractice Insurance

15.

$

5,000.00

16.

Other Client Examination Expenses

16.

$

240.00

17.

Total Other Client Examination Expenses

17.

$

33,040.00

 

(Sum of lines 9 through 16)

 

Total on line 17 is equal to BCRR Table 6,

 

worksheet A, Column I, line 1.

DONATED MEDICAL EXPENSES

18.

Value of Physician’s Donated Time

18.

$

.00

19.

Value of Nurse Midwife/N.P.’s Donated Time

19.

$

.00

20.

Value of R.N.’s Donated Time

20.

$

6,000.00

21.

Value of LPN’s Donated Time

21.

$

.00

22.

Value of other Donated Medical Expenses

22.

$

.00

23.

Total Donated Services and Materials

23.

$

6,000.00

 

(Sum of lines 18 through 22)

 

Total on line 23 is equal to BCRR Table 6,

 

worksheet A, Column j, line 1.

PATIENT EXAM INDIRECT COSTS

24.

Medical Fringe Benefits

24.

$

18,291.00

 

(Worksheet A – Column g, line 1)

25.

Medical Facility Costs

25.

$

11,984.00

 

(Worksheet B – Column d, line 1)

26.

Administrative Costs

26.

$

37,724.00

 

(Worksheet B – Column g, line 1)

To arrive at the total medical costs you will add salary and wages (8), other costs (17) and donated services and materials (23) to the fringe benefits (24), facility costs (25) and administrative costs (26).

27.

Total Medical Costs

27.

$

265,389.00

 

This total equals BCRR Table 6, Column g, line 1.

LABORATORY COST CENTER

LABORATORY SERVICES DIRECT EXPENSES

28.

Salaries and Wages (include only those staff who perform

 

tests, assist in tests or prepare specimens)

28.

$

7,000.00

29.

Total

29.

$

7,000.00

 

Total on line 29 is equal to BCRR Table 6,

 

worksheet A, Column E, line 2.

OTHER LABORATORY EXPENSES

30.

Laboratory Equipment Lease or Rental Expense

30.

$

.00

31.

Laboratory Equipment Depreciation Expense

31.

$

200.00

32.

Laboratory Equipment Maintenance and Repair Expense

32.

$

.00

33.

Laboratory Supplies Expense

33.

$

3,000.00

34.

Purchased Outside Laboratory Services Expense

34.

$

19,792.00

 

See page 35.

35.

Other Laboratory Expenses

35.

$

.00

36.

Total Other Laboratory Services Expenses

36.

$

22,992.00

 

(Sum of lines 30 through 35)

 

Total on line 36 is equal to BCRR Table 6,

 

worksheet A, Column I, line 2.

DONATED LABORATORY EXPENSES

37.

Value of Lab Technician’s Donated Time

37.

$

.00

38.

Value of Donated Lab Supplies

38.

$

.00

39.

Value of Donated Lab Tests

39.

$

1,200.00

40.

Value of other Donated Lab Expenses

40.

$

.00

41.

Total Donated Laboratory Services and Materials

41.

$

1,200.00

 

(Sum of lines 37 through 40)

 

Total on line 41 is equal to BCRR Table 6,

 

worksheet A, Column j, line 2.

LABORATORY SERVICES INDIRECT EXPENSES

42.

Laboratory Fringe Benefits

42.

$

819.00

 

(Worksheet A – Column g, line 2)

43.

Laboratory Facility Costs

43.

$

1,598.00

 

(Worksheet B – Column d, line 2)

44.

Laboratory Administration Cost

44.

$

5,716.00

 

(Worksheet B – Column g, line 2)

To arrive at the total laboratory expenses you will add salary and wages (29), other costs (36) and donated services and materials (41) to the fringe benefits (42), facility costs (43) and administrative costs (44).

45.

Total Laboratory Costs

45.

$

39,325.00

 

This total equals BCRR Table 6, Column g, line 2.

OUTSIDE LABORATORY TESTS:

Any laboratory test completed by an outside incorporated entity.  An invoice and payment to the entity for services must exist.

If you have “purchased outside laboratory fees” which will be included in total laboratory expenses for your BCRR information, you must now subtract the dollar amount of those purchases from your BCRR total on Table 6, Column G, line 2 to arrive at the dollar amount to be used in your total adjusted cost/center of Attachment C, Column E. You WILL NOT use the amount from your BCRR Table 6, Column G, line 2 for this amount.

OUTSIDE LABORATORY COST AREA

Type of Supply

Your Cost/Unit

x

Number Used

=

Total Expense*

46.

VDRL/RPR

4.00

x

8

46.

$

32.00

47.

Pap Smear

3.50

x

4,000

47.

$

14,000.00

48.

Gonorrhea Culture

6.50

x

8

48.

$

52.00

49.

Miscellaneous Culture

18.00

x

40

49.

$

720.00

50.

Sickle Cell

5.00

x

100

50.

$

500.00

51.

P.P. Blood Glucose

4.50

x

20

51.

$

90.00

52.

Cholesterol Level

4.00

x

10

52.

$

40.00

53.

SMA 12

6.75

x

10

53.

$

68.00

54.

Colposcopy

40.00

x

4

54.

$

160.00

55.

Colposcopy and Biopsy

50.00

x

1

55.

$

50.00

56.

Chlamydia

8.00

x

510

56.

$

4,080.00

57.

Total Outside Laboratory Fees

57.

$

19,792.00

58.

Adjusted Total Cost Center:

58.

$

19,533.00

 

Line 45, subtract Line 57

*Round to the nearest dollar amount. equals amount on Line 58.

This is the amount to be used in the Adjusted Total

Cost/Center, Attachment C, Column E

PHARMACY COST CENTER

Supplies Consumed During Reporting Period:

Type of Supply

Your Cost/Unit

x

Number Used

=

Total Expense**

59.

Oral Contraceptives

.70

x

58,500

59.

$

40,950.00

60.

Cream

1.00

x

54

60.

$

54.00

61.

Jelly

1.00

x