Form Cms-339 - Provider Cost Report Reimbursement Questionnaire Page 20
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251102.3 (Cont.)
EXHIBIT 4A (Cont.)
04-06
Provider Name __________________________________Provider Number ___________________________
Name of Physician _________________________________________________________________________
4.
Determine the Allowance for Malpractice Insurance (Supervision and Administration
(S&A)):
Supervisory and Administrative Hours
X Total Payment for Malpractice Insurance
= Allowance
Total Hours Worked
_______________________________ X $_______________________
= $_______________
5.
Adjusted RCE Base for Supervision and Administrative Services:
(Sum of #1 _____________ + the Lesser of #2 or #3 _____________+ #4________________)
= $_______________
6.
Determine Provider Payments Attributable to Supervision and Administrative Services:
Supervision and Administration (S&A):
S& A Hours X Rate
__________ X $ ________________
= $_______________
Membership in Professional Associations:
S&A Hours X Cost
Total Hours
__________ X $________________
= $_______________
Continuing Medical Education:
S&A Hours X Cost
Total Hours
__________ X $________________
= $_______________
Malpractice Insurance Premiums:
S&A Hours X Cost
Total Hours
__________ X $________________
= $_______________
Total
= $_______________
7.
Amount Includable in Allowance Costs
(Lesser
of #5 or #6)
= $_______________
11-34
Rev. 6
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