ABC Hospice
Provider No. 46-XXXX
Calculation of Estimated CAP Overpayment (Underpayment)
Patients Making Initial Hospice Election Between 9/28/07 and 9/27/08
CAP Year Ended 10/31/08
Patient Initial Days on service Days on service Pro-rata
Count Name HIC# Election Date with other agencies with ABC allocation
1 Patient Name 123456789 9/29/2007 #DIV/0!
2 Patient Name 123456789 10/1/2007 #DIV/0!
3 Patient Name 123456789 12/8/2007 30 30 0.50
4 Patient Name 123456789 12/13/2007 #DIV/0!
5 Patient Name 123456789 12/14/2007 #DIV/0!
6 Patient Name 123456789 12/18/2007 #DIV/0!
7 Patient Name 123456789 12/21/2007 1200 310 0.79
8 Patient Name 123456789 12/26/2007 #DIV/0!
9 Patient Name 123456789 1/2/2008 #DIV/0!
10 Patient Name 123456789 1/13/2008 24 2 0.92
11 Patient Name 123456789 1/16/2008 #DIV/0!
12 Patient Name 123456789 1/27/2008 #DIV/0!
13 Patient Name 123456789 2/9/2008 41 75 0.35
14 Patient Name 123456789 2/9/2008 #DIV/0!
15 Patient Name 123456789 2/9/2008 #DIV/0!
16 Patient Name 123456789 2/14/2008 8 89 0.08
17 Patient Name 123456789 2/17/2008 #DIV/0!
18 Patient Name 123456789 2/24/2008 #DIV/0!
19 Patient Name 123456789 3/7/2008 #DIV/0!
20 Patient Name 123456789 3/9/2008 6 18 0.25
21 Patient Name 123456789 4/1/2008 #DIV/0!
22 Patient Name 123456789 4/28/2008 #DIV/0!
23 Patient Name 123456789 4/28/2008 #DIV/0!
24 Patient Name 123456789 5/5/2008 #DIV/0!
25 Patient Name 123456789 5/11/2008 90 174 0.34
3.24
Total Beneficiary count
(with initial election between 9/28/07-9/27/08) 25.00
2008 Cap Amount $22,386.18
Agregate CAP limit $559,654.50
Total Payments for dates of service from
11/01/07 to 10/31/08 $575,430.00
CAP Overpayment (underpayment) $15,775.50
Beneficiary count pro-rated to other Hospice Agencies 3.24
Reduction to Aggregate Cap for pro-ration of beneficiary count $ 72,634.43
Net Cap Overpayment (Underpayment) $88,409.93
Scott Jolley, CPA phone 274-8866