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CBM-5

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CBM-5

    CBM-5

    STATEMENT OF REVENUE AND EXPENSES

    INSTRUCTIONS

Data must be provided for two fiscal years projected actual and budget. For the projected

    actual fiscal year, provide data based on actual year to date plus data projected for the

    remaining months of the fiscal year.

     Column A Total -

Lines 1 14 Enter all data required by utilizing the hospital records.

Line 3 Enter total amount of Uncollectible Accounts.

Line 4 Enter total amount of charity care for all payors.

Line 6 Enter total Operating Expenses. The amount on this line should be the total

    operating expenses, but DO NOT include Uncollectible Accounts (bad debts)

    at the charge level and Federal and State income tax.

     NOTE: Collections for Uncollectible Accounts previously

    written off should be netted against the Uncollectible

    Accounts.

    NOTE: Total operating expenses on Line 6 must equal CBM-4

    - Line 3.

Line 12 Extraordinary items, if any, are to be recorded on this line. Extraordinary items

    must meet the criteria in generally accepted accounting principles. A full

    explanation describing the nature of the extraordinary item must be

    attached.

Column B- Medicare; Column C Medicaid; Column D PEIA; Column E Other

    Governmental and Columns F and G Non-governmental (Inpatient and

    Outpatient) -

HCA April - 2010

Line 1 Calculate and enter total Gross Patient Revenue for each payor group.

Line 2 Calculate Contractual Allowances associated with each payor group.

Line 3 Enter amount of Uncollectible Accounts associated with each payor group if

    applicable.

Line 4 Enter total amount of charity care for each payor group, if applicable.

Line 5 Enter the total amount of reimbursement received (and receivable) from each

    payor group.

Line 6 Calculate Operating Expenses associated with each payor group. Operating

    Expenses must be calculated as a percent of each payor groups Gross Patient

    Revenue to Total Revenue.

     NOTE: Collections for Uncollectible Accounts previously

    written off should be netted against the Uncollectible

    Accounts.

Line 7 Calculate Income from Patients: Net Patient Revenue less Operating

    Expenses for each payor group.

    NOTE: Disproportionate Share Revenues, if applicable, are to

    be entered in the space provided on the form and also netted

    against Medicaid Contractual Allowances.

     DO NOT include unrealized gains and/or losses in the EROE.

    See Financial Disclosure Policy Statement 97-4, dated July 30,

    1997 and clarification memo dated October 17, 2002 for further

    information.

    HCA April - 2010

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