2024-08-07T07:56:59-05:00 2023-09-30 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2023-01-01 390944012 MOUNDVIEW MEMORIAL HOSPITAL & CLINICS MOUN 6083393331 402 WEST LAKE STREET FRIENDSHIP WI 53934 FRANK PEREZ-GUERRA CEO 6083393331 2024-07-30 1 0 MICHAEL J PETERSON CPA P01833529 2187224705 2024-07-30 2023 2024-08-08 14:25:15Z GUNDERSEN MOUNDVIEW HOSPITAL & CLINICS FRANK PEREZ-GUERRA 402 WEST LAKE STREET FRIENDSHIP WI 53934 25545568 0 X WWW.GUNDERSENHEALTH.ORG/MOUNDVIEW X 1959 WI TOGETHER, WE INSPIRE YOUR BEST LIFE BY RELENTLESSLY CARING, LEARNING AND INNOVATING. 9 4 0 65 0 0 596964 92084 28523764 24924368 67633 359449 207882 159664 29396243 25535565 551107 0 0 0 9471727 8400294 0 0 0 19030738 15846048 29053572 24246342 342671 1289223 19154587 21024749 2121251 2702190 17033336 18322559 TOGETHER, WE INSPIRE YOUR BEST LIFE BY RELENTLESSLY CARING, LEARNING AND INNOVATING. 0 0 13297712 0 15888769 THE HOSPITAL IS A GENERAL MEDICAL CRITICAL ACCESS HOSPITAL LICENSE FOR 25 BEDS. DURING FISCAL YEAR 2023, THE HOSPITAL HAD 440 ACUTE PATIENT DAYS AND 870 SWING BED DAYS. THE HOSPITAL ALSO HAD 6,285 EMERGENCY ROOM/URGENT VISITS AND 8,455 CLINIC VISITS. 7885038 0 9079838 THE HOSPITAL ALSO HAS AN OUTPATIENT PHARMACY THAT IS THE ONLY IN IT'S COUNTY (ADAMS, WI), AND IN 2023 FILLED 52,239 PRESCRIPTIONS. 21182750 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 9 4 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 WI X FRANK PEREZ-GUERRA 6083393331 402 WEST LAKE STREET FRIENDSHIP WI 53934 X SCOTT RATHGABER CEO-GHS 1.00 40.00 X 0 0 0 GERALD OETZEL CFO-GHS (THRU 08/23) 1.00 40.00 X 0 0 0 STEVE LITTLE CFO-GHS (BEG 08/23) 1.00 40.00 X 0 0 0 FRANK PEREZ-GUERRA CEO 40.00 1.00 X 0 0 0 TADD WORMET CHAIR 2.50 X X 0 0 0 RICHARD STERNHAGEN CHAIR (TERMED JAN) 2.50 1.00 X X 0 0 0 PAUL FISCH VICE CHAIR 2.50 40.00 X X 0 0 0 SARAH ROSSMAN TREASURER/SECRETARY 2.50 40.00 X X 0 0 0 STEPHANIE CARROLL BOARD TRUSTEE/MD HOSPITALIST 2.50 40.00 X 0 0 0 BRYAN ERDMANN BOARD TRUSTEE/COO 2.50 40.00 X 0 0 0 LAURIE INDA BOARD TRUSTEE 2.50 X 0 0 0 KAREN MILLER BOARD TRUSTEE 2.50 X 0 0 0 ROXANNE POTTS BOARD TRUSTEE/CLINICAL OPS. DIRECTOR 2.50 40.00 X 0 0 0 JOE THEISEN BOARD TRUSTEE 2.50 X 0 0 0 0 0 0 0 0 0 0 0 78481 13444 159 92084 NET PATIENT SERVICE REVENUE 621300 15799104 15799104 PHARMACY 456110 9079838 9079838 MEDICAL BUILDING RENT 531120 38798 38798 6628 6628 24924368 359449 359449 13406 10003 3403 3403 3403 E.H.R INCENTIVE 900099 44239 44239 CAFETERIA 722514 25480 25480 86542 86542 156261 25535565 24968607 0 474874 X 166748 166748 6641752 5640051 1001701 105937 84251 21686 1040268 834017 206251 445589 360891 84698 8950 8950 4304 4304 7109136 5913367 1195769 38820 4834 33986 412561 303409 109152 15294 14460 834 281694 254149 27545 132827 130948 1879 24746 12390 12356 4699 4486 213 398882 332969 65913 53314 1722 51592 MEDICAL SUPPLIES 6594924 6594924 PHARMACY DRUGS AND VACC 264780 264780 EQUIPMENT REPAIRS AND M 227363 219771 7592 BAD DEBT EXPENSE 142249 142249 131505 69082 62423 24246342 21182750 3063592 0 875 1175 9233752 10781880 2492118 3049390 635752 702338 59090 80154 9164809 3571254 5670130 5593555 744167 731667 318703 84590 19154587 21024749 1349717 1559189 41076 3658 226262 201991 504196 937352 2121251 2702190 X 16500336 17783559 533000 539000 17033336 18322559 19154587 21024749 1289223 0 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 4304 4304 0 PART II-B, LINE 1: MOUNDVIEW MEMORIAL HOSPITAL & CLINICS PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE WISCONSIN HOSPITAL ASSOCIATION (WHA) & AMERICAN HOSPITAL ASSOCIATION VIA WHA.. THESE DUES ARE PRIMARILY FOR ACCESS TO EDUCATIONAL MATERIALS AND STAFF TRAINING AND DEVELOPMENT. THE WHA HAS NOTIFIED MOUNDVIEW MEMORIAL HOSPITAL & CLINICS THAT $4,304 OF THE COMBINED ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. 76500 76500 6089254 1510175 4579079 2611655 1692495 919160 387400 368584 18816 5593555 OPERATING LEASE OBLIGATIONS 3153 DUE TO RELATED PARTY 459904 PAYABLES TO THIRD-PARTY REIMBURSEMENT PROGRAMS 474295 937352 X PART X, LINE 2: GUNDERSEN HEALTH SYSTEM HAS REVIEWED TAX POSITIONS FOR ALL OPEN YEARS AND HAS CONCLUDED THAT NO LIABILITIES EXIST FOR UNCERTAIN TAX POSITIONS. THE SYSTEM'S INCOME TAX RETURNS ARE NO LONGER SUBJECT TO EXAMINATION FOR 2018 AND PRIOR YEARS. 1 1 X 1 X 1 X 1 1 1 0 1 1 369456 369456 0.01520 3135994 2206493 929501 0.03830 3505450 2206493 1298957 0.05350 165793 4300 161493 0.00670 11670 11670 0.00050 6138551 4558475 1580076 0.06520 6316014 4562775 1753239 0.07240 9821464 6769268 3052196 0.12590 1 76693 3221 4997979 5027655 -29676 X 1 1 1 1 MOUNDVIEW MEMORIAL HOSPITAL & CLINICS 402 WEST LAKE STREET PO BOX 40 FRIENDSHIP WI 53934 WWW.GUNDERSENHEALTH.ORG/MOUNDVIEW 1014 X X X X MOUNDVIEW MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 21 1 1 1 1 X SEE SUPPLEMENTAL INFORMATION X 1 21 1 SEE SUPPLEMENTAL INFORMATION 0 1 X 200.000000000000 400.000000000000 X X X X X X X 1 1 X X X X 1 X HTTPS://WWW.GUNDERSENHEALTH.ORG/DOCUMENT/23076 X HTTPS://WWW.GUNDERSENHEALTH.ORG/DOCUMENT/23076 X HTTPS://WWW.GUNDERSENHEALTH.ORG/DOCUMENT/23076 X X X X X X 1 X 0 X X X X 1 X 0 0 MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: A 52 QUESTION SURVEY WAS AVAILABLE FOR COMMUNITY MEMBERS TO COMPLETE FROM JUNE 14-AUGUST 8, 2021. THE SURVEY WAS AVAILABLE ONLINE VIA SURVEY MONKEY AND SHARED THROUGH FACEBOOK AND EMAILS TO VARIOUS COMMUNITY BUSINESS, AGENCIES, COALITION MEMBERS, AND CHURCHES. PAPER COPIES WERE AVAILABLE AT HEALTH & HUMAN SERVICES, GUNDERSEN MOUNDVIEW, LIBRARIES IN ADAMS, ROME AND WI DELLS, THE COUNTY FAIR, AREA FOOD PANTRIES, FRIENDSHIP CONNECTION, AND WAS DISTRIBUTED TO THE COUNTY'S MEALS ON WHEELS RECIPIENTS. A SURVEY WAS TRANSLATED INTO SPANISH WITH COPIES SENT TO AREA FARMS THAT EMPLOY SPANISH SPEAKING WORKERS. PRESS RELEASES WERE SENT AND ADS PLACED THROUGH LOCAL MEDIA. THERE WERE 607 RESPONDENTS. TWO COMMUNITY FOCUS GROUPS WERE ALSO SCHEDULED AND ADVERTISED WITH NO ONE ATTENDING. TWO FOCUS GROUPS FOR COMMUNITY STAKEHOLDERS WERE HELD WITH TEN PARTICIPANTS. THERE WERE ALSO 23 KEY INFORMANT INTERVIEWS WITH COMMUNITY MEMBERS AND KEY STAKEHOLDERS. COMMUNITY STAKEHOLDER PARTICIPANTS INCLUDED MEDICAL PROVIDERS, SERVICE AGENCIES, SCHOOL LEADERS, COUNTY GOVERNMENT, BUSINESS LEADERS AS WELL AS MANY OTHERS WHO REPRESENTED LOW INCOME AND DISABILITY POPULATIONS. MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 6A: ASPIRUS AND SSM HEALTH CARE ST. CLARE HOSPITAL ALSO PARTICIPATED IN THE COUNTY-WIDE NEEDS ASSESSMENT HOSTED IN IN 2021 BY PUBLIC HEALTH. OUR NEEDS ASSESSMENT INCLUDES BRIEF INFO SPECIFIC TO US THAT IS THEN ATTACHED TO THE COUNTY-WIDE ASSESSMENT MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: ADAMS COUNTY HEALTH AND HUMAN SERVICES - DIVISION OF PUBLIC HEALTH AND GREAT RIVERS UNITED WAY MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: GUNDERSEN MOUNDVIEW IS ADDRESSING IDENTIFIED HEALTH NEEDS THROUGH COUNTY AND HOSPITAL SPECIFIC IMPLEMENTATION PLANS. THE INITIAL IDENTIFICATION OF HEALTH PRIORITIES THROUGH THE ASSESSMENT ARE, OVERALL, ENCOMPASSED IN OUR FOUR HOSPITAL PRIORITY AREAS. IN 2022, TWO COUNTY PUBLIC HEALTH COMMUNITY ACTION TEAMS WERE ESTABLISHED - MENTAL HEALTH AND ACCESS TO CARE. THE HOSPITAL PARTICIPATED WITH OTHER AGENCIES IN BOTH OF THESE GROUPS TO CONDUCT A GAP ANALYSIS, GOALS, SMART OBJECTIVES, AND WORK PLANS FOR IDENTIFIED HEALTH NEEDS.ADDITIONAL WORK TEAMS WERE FORMED FROM THE INITIAL CAT GROUPS SUCH AS TRANSPORTATION AND RECRUITMENT AND RETENTION OF HEALTHCARE PROVIDERS. THE TRANSPORTATION GROUP CONDUCTED A GAP ANALYSIS AND HAS BEEN MEETING WITH OTHER RURAL TRANSPORTATION AGENCIES TO DETERMINE THE FEASIBILITY OF ESTABLISHING A LOCAL TRANSIT SYSTEM. THE HOSPITAL ALSO PARTNERED WITH THE HIGH SCHOOL AND TECHNICAL COLLEGE ON ESTABLISHING A HEALTHCARE CAREER ACADEMY AT THE HIGH SCHOOL. THE HOSPITAL PARTICIPATES IN THE FEDERAL RURAL PARTNERS NETWORK PROGRAM TO IMPROVE RURAL ECONOMIC DEVELOPMENT. ITS INITIATIVES INCLUDE TRANSPORTATION, WORKFORCE DEVELOPMENT, HOUSING, CHILDCARE AND IMPROVING THE DOWNTOWN. AND, WE PARTNERED WITH UW EXTENSION TO RE-ESTABLISH BABYSITTING CLASSES. RECENTLY, THE HOSPITAL INSTALLED A NEW MEDICATION DROP BOX FOR PATIENTS TO SAFELY DISPOSE OF UNWANTED MEDICATIONS. WE ALSO PARTICIPATED IN THE ESTABLISHMENT THE NUTRITION AND PHYSICAL ACTIVITY CAT GROUP BASED ON IDENTIFIED HEALTH NEEDS. IN ADDITION, THE HOSPITAL HAS CONTINUED TO SERVE ON NUMEROUS COMMUNITY COALITIONS AND PROVIDED SCHOOL SUPPORT THROUGH SERVING ON THE 2023 REFERENDUM COMMITTEE AND CONTINUING THE LOCAL STUDENT MENTORING PROGRAM. WE ANNUALLY REVIEW PROGRESS ON OUR GOALS. WE CONTINUE TO PROMOTE MENTAL HEALTH AWARENESS THROUGH SERVING ON THE MAN THERAPY COMMITTEE, AND PLANNING COMMITTEE FOR THE SUICIDE PREVENTION WALK (AS WELL AS SPONSORSHIP OF THE EVENT). MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 13H: HOSPITAL PATIENTS NOT MEETING FINANCIAL ASSISTANCE ELIGIBILITY THRESHOLDS MAY BE ELIGIBLE FOR ASSISTANCE UNDER CIRCUMSTANCES WHEN HOSPITAL MEDICAL BILLS WOULD RESULT IN SEVERE FINANCIAL HARDSHIP. PATIENTS, OR THEIR GUARANTORS, MAY BE ELIGIBLE FOR CATASTROPHIC CARE ASSISTANCE IF THEY HAVE INCURRED OUT-OF-POCKET OBLIGATIONS RESULTING FROM MEDICAL SERVICES PROVIDED BY GMV THAT EXCEED 25% OF FAMILY INCOME AND HAVE ASSETS BELOW THE EQUIVALENT OF 600% OF THE FPL THRESHOLD. PART V, SECTION B LINE 7A HTTPS://WWW.GUNDERSENHEALTH.ORG/DOCUMENT/22396 PART V, SECTION B LINE 10A HTTPS://WWW.GUNDERSENHEALTH.ORG/DOCUMENT/22416 2 1 - GUNDERSEN MOUNDVIEW FRIENDSHIP CLINIC 402 WEST LAKE STREET PO BOX 40 FRIENDSHIP WI 53934 RURAL HEALTH CLINIC 2 - GUNDERSEN MOUNDVIEW WESTFIELD CLINIC 207 NORTH PIONEER PARK ROAD WESTFIELS WI 53964 RURAL HEALTH CLINIC PART I, LINE 3C: HOSPITAL PATIENTS NOT MEETING FINANCIAL ASSISTANCE ELIGIBILITY THRESHOLDS MAY BE ELIGIBLE FOR ASSISTANCE UNDER CIRCUMSTANCES WHEN HOSPITAL MEDICAL BILLS WOULD RESULT IN SEVERE FINANCIAL HARDSHIP. PATIENTS, OR THEIR GUARANTORS, MAY BE ELIGIBLE FOR CATASTROPHIC CARE ASSISTANCE IF THEY HAVE INCURRED OUT-OF-POCKET OBLIGATIONS RESULTING FROM MEDICAL SERVICES PROVIDED BY GMV THAT EXCEED 25% OF FAMILY INCOME AND HAVE ASSETS BELOW THE EQUIVALENT OF 600% OF THE FPL THRESHOLD. PART I, LINE 7: THE RATIO OF PATIENT COST TO CHARGES WAS CALCULATED BY DIVIDING HOSPITAL EXPENSES NET OF NON-PATIENT REVENUE AND IDENTIFIED COMMUNITY BENEFIT EXPENSE BY GROSS PATIENT REVENUE. THE PERCENTAGE WAS THEN MULTIPLIED BY THE GROSS REVENUES ON BAD DEBT ACCOUNTS. PART I, LINE 7G: THE ORGANIZATION OPERATES 2 RURAL HEALTH CLINICS, AN OBSERVATION ROOM AND EMERGENCY ROOM WHERE THE COSTS EXCEED THE NET PATIENT SERVICE REVENUE. THESE SERVICES WOULD NOT BE PROVIDED TO THE COMMUNITY IF NOT FOR THE LEADERSHIP OF THE HOSPITAL. THE ORGANIZATION UTILIZED THEIR COST REPORT AND OTHER INTERNAL INFORMATION TO DETERMINE THE AMOUNTS TO BE RECORDED PER WORKSHEET 6 OF THE IRS FORM SCHEDULE H INSTRUCTIONS. AMOUNTS RECORDED HERE HAVE NOT BEEN DUPLICATED IN OTHER AREAS OF THE FORM, MEDICAID, BAD DEBT, FINANCIAL ASSISTANCE HAS BEEN REMOVED FROM THE AMOUNTS REPORTED AND THESE SERVICES WERE EXCLUDED FROM THE MEDICARE SURPLUS/SHORTFALL CALCULATION. PART II, COMMUNITY BUILDING ACTIVITIES: THE HOSPITAL'S COMMUNITY BUILDING ACTIVITIES PROMOTES HEALTH OF THE COMMUNITIES IT SERVES THROUGH LOCAL ADVERTISEMENTS, INVOLVEMENT WITH CHAMBER OF COMMERCE, DEPARTMENT OF AGING AND OTHER COMMUNITY ORGANIZATIONS. THE AMOUNT OF SUPPORT IS DIFFICULT TO QUANTIFY. PART III, LINE 2: THE RATIO OF PATIENT COST TO CHARGES WAS CALCULATED BY DIVIDING HOSPITAL EXPENSES NET OF NON-PATIENT REVENUE AND IDENTIFIED COMMUNITY BENEFIT EXPENSE BY GROSS PATIENT REVENUE. THE PERCENTAGE WAS THEN MULTIPLIED BY THE GROSS REVENUES ON BAD DEBT ACCOUNTS. PART III, LINE 3: IT IS CONSIDERED COMMUNITY BENEFIT AS THE HOSPITAL IS REIMBURSED ON MEDICARE ALLOWABLE COSTS. MEDICARE ALLOWABLE COSTS ARE DEFINED BY MEDICARE. THEY DO NOT NECESSARILY CAPTURE ALL COSTS OF THE HOSPITAL PROVIDING SERVICES TO THE COMMUNITY. CONSEQUENTLY, THERE ARE COSTS NOT REIMBURSED BY EITHER PATIENT OR THE PROGRAM. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE ARE RECORDED IN THE ACCOMPANYING CONSOLIDATED BALANCE SHEETS NET OF CONTRACTUAL ADJUSTMENTS AND AN ALLOWANCE FOR DOUBTFUL ACCOUNTS, THAT REFLECTS MANAGEMENT'S BEST ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED. MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH A REDUCTION OF GROSS PATIENT SERVICE REVENUE AND A CREDIT TO PATIENT ACCOUNTS RECEIVABLE. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY FROM UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND CURRENT STATUS OF INDIVIDUAL ACCOUNTS.IN EVALUATING THE COLLECTABILITY OF PATIENT ACCOUNTS RECEIVABLE, THE ORGANIZATION ANALYZES PAST RESULTS AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. SPECIFICALLY, FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE ORGANIZATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE .EXISTS FOR PART OF THE BILL). THE ORGANIZATION RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE BASED ON ITS EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. PART III, LINE 8: THE TOTAL MEDICARE REVENUE SHOWN IN SCHEDULE H TO THE FORM 990 IS BASED ON THE IRS 990 INSTRUCTIONS AND INCLUDES ONLY A PORTION OF THE GROSS MEDICARE REVENUE OF THE ORGANIZATION AND DOES NOT CONSIDER ALL CONTRACTUAL ADJUSTMENTS FOR SERVICES REIMBURSED BY THE MEDICARE PROGRAM. AMOUNTS LISTED FOR MEDICARE REVENUE DO NOT INCLUDE PHYSICIAN SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT THE ORGANIZATION AS WELL AS ANESTHESIA PROFESSIONAL SERVICES, SURGICAL PHYSICIAN PROFESSIONAL SERVICES, AND REVENUE FOR ANY PATIENTS COVERED UNDER MEDICARE ADVANTAGE PLAN PROGRAMS. PHYSICIAN PROFESSIONAL SERVICES ARE REIMBURSED PRIMARILY ON FEE SCHEDULE REIMBURSEMENTS AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY, SURGICAL, AND CLINICAL PHYSICIAN SERVICES PROVIDED TO MEDICARE PATIENTS ARE VITAL TO THE WELL-BEING OF THE COMMUNITY AND AS SUCH THESE COSTS AND SHORTFALLS SHOULD ALSO BE CONSIDERED AS AN ADDITIONAL BENEFIT THAT MOUNDVIEW MEMORIAL HOSPITAL & CLINICS PROVIDES TO THE COMMUNITY AND SURROUNDING AREAS. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON THE FILED MEDICARE COST REPORT, AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES, AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUE (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE).WHETHER THERE IS A SHORTFALL OR SURPLUS ON SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PEOPLE, WHICH ARE TYPICALLY ELDERLY OR DISABLED MEMBERS OF THE COMMUNITY, ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. PART III, LINE 9B: PATIENTS UPON REGISTRATION ARE GIVEN THE POLICY AND REQUIREMENTS TO BE ELIGIBLE FOR CHARITY CARE. THEY ARE ENCOURAGED BY A FINANCIAL ADVISOR TO REVIEW THEIR SITUATION FOR ELIGIBILITY. PART VI, LINE 2: THE HOSPITAL COMMUNICATES REGULARLY WITH PUBLIC HEALTH TO ADDRESS COMMUNITY HEALTH NEEDS. WE ANNUALLY REVIEW LOCAL, REGIONAL AND STATE DATA SOURCES. THE HOSPITAL COMPLETES REPORTS ON INFECTIOUS AND COMMUNICABLE DISEASE AND MONITORS FOR OUTBREAKS. ANNUAL RISK ASSESSMENTS CARE COMPLETED ON TB AND INFECTION CONTROL ISSUES. THE HOSPITAL MEASURES CHRONIC DISEASE SCREENING RATES. THE HOSPITAL REVIEWS DATA RELEVANT TO WORK BEING COMPLETED THROUGH THE LOCAL COMMUNITY ACTION TEAMS WHO ARE ADDRESSING THE PRIORITIZED HEALTH NEEDS. PART VI, LINE 3: THE HOSPITAL ANNUALLY UPDATES THE AVAILABILITY OF ITS CHARITY PLAN AND QUALIFYING INCOME NEEDS TO QUALIFY ON THE HOSPITAL WEBSITE. THE EXISTENCE OF A CHARITY PLAN IS POSTED IN THE ADMITTING AREA. UPON REGISTRATION, THE PATIENT IS INFORMED OF THE HOSPITAL'S CHARITY PLAN, ELIGIBILITY, AND METHODS FOR APPLYING. ANYONE INTERESTED IN FURTHER INFORMATION IS REFERRED TO THE PATIENT ACCOUNT COORDINATOR FOR QUESTIONS AND ELIGIBILITY. THIS PERSON WORKS WITH THE PATIENT IN APPLICATION AS WELL AS EXPLORING THE POSSIBLE ELIGIBILITY OF ANY OTHER GOVERNMENT PROGRAM THAT MAY BE APPLICABLE, I.E. MEDICAID, BADGER CARE. PART VI, LINE 4: GUNDERSEN MOUNDVIEW SERVES ALL RESIDENTS OF ADAMS COUNTY (POPULATION 21,226 PER CENSUS 2022 QUICK FACTS). WE ALSO SERVE WESTFIELD AREA RESIDENTS, LOCATED IN MARQUETTE COUNTY. HOWEVER, OUR PRIMARY SERVICE AREA IS THE CENTRAL PORTION OF ADAMS COUNTY INCLUDING THE ZIP CODES OF ADAMS, FRIENDSHIP, ARKDALE AND GRAND MARSH WHICH MAKE UP OVER 74% OF OUR REVENUE. THE MAJORITY OF ADAMS COUNTY RESIDENTS ARE WHITE (93.1%) AND A HIGH PERCENTAGE (32%) ARE AGE 65 AND OVER. THE MEDIAN HOUSEHOLD INCOME ($55,223) IS CONSIDERABLY LOWER THAN THE STATE. TOURISM AND AGRICULTURE ARE AMONG THE COUNTY'S LARGEST INDUSTRIES. THE COUNTY IS MEDICALLY UNDERSERVED AND HAS RANKED IN THE BOTTOM OF THE WI COUNTY HEALTH RANKINGS IN TERMS OF HEALTH OUTCOMES AND FACTORS. PART VI, LINE 5: THE HOSPITAL IS A STRONG COMMUNITY PARTNER IN MANY LOCAL HEALTH EFFORTS. WE PROVIDE MONETARY AND IN-KIND SUPPORT TO SEVERAL INITIATIVES SUCH AS DONATIONS TO RECREATIONAL/WELLNESS PROGRAMS (SUCH AS DONATIONS TO YOUTH RECREATIONAL SPORTS, CORPORATE DONATION TO THE YMCA CAMPAIGN AND MONETARY DONATION TO SUPPORT A LOCAL MENTAL HEALTH SEMINAR). WE ALSO HAVE A PHYSICIAN SERVING ON THE LOCAL HEALTH BOARD, STAFF SERVING ON NUMEROUS COMMUNITY COALITIONS, COLLECT DONATIONS FOR AREA FOOD PANTRIES AND MUCH MORE. THESE ARE JUST A FEW AREAS WE HAVE ASSISTED. THE HOSPITAL BOARD ALSO INCLUDES COMMUNITY MEMBERS WHO ARE UNPAID. PART VI, LINE 6: THE ORGANIZATION IS PART OF GUNDERSEN HEALTH SYSTEM. EACH AFFILIATE DEVELOPS ITS OWN NEEDS ASSESSMENT AND IMPLEMENTATION PLAN, WITH SUPPORT FROM THE SYSTEM AS NEEDED. THE SYSTEM HOLDS QUARTERLY COMMUNITY BENEFIT MEETINGS AMONG THE AFFILIATES TO REVIEW PROGRESS ON GOALS. PART VI, LINE 7, REPORTS FILED WITH STATES WI X X 0 0 0 0 0 0 0 0 0 PART I, LINE 3 PURSUANT TO IRS FORM 990 INSTRUCTIONS, THIS SHORT PERIOD RETURN COVERS THE DATES 01/01/2023 THROUGH 09/30/2023 AND THERE IS NO CALENDAR YEAR ENDING WITHIN THE PERIOD AND THUS NO REPORTABLE COMPENSATION. A RELATED ORGANIZATION OF THE FILING ORGANIZATION USES ONE OR MORE OF THE FOLLOWING TO ESTABLISH THE COMPENSATION OF THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL: -COMPENSATION COMMITTEE -INDEPENDENT COMPENSATION CONSULTANT -COMPENSATION SURVEY OR STUDY, AND -APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE PLEASE REFER TO THE FORM 990, PART VI, LINE 15A DISCLOSURE IN SCHEDULE O FOR ADDITIONAL DETAILS ON HOW COMPENSATION OF THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL IS ESTABLISHED. FORM 990, PART VI, SECTION A, LINE 6 THE HOSPITAL HAS A NINE MEMBER BOARD OF DIRECTORS COMPRISED OF FIVE MEMBERS FROM THE HEALTH SYSTEM AND FOUR COMMUNITY DIRECTORS CHOSEN FROM OUR LOCAL SERVICE AREA. FORM 990, PART VI, SECTION A, LINE 7A THE BOARD OF DIRECTORS SOLICITS NOMINATIONS FROM CANDIDATES TO FILL OPEN BOARD SEATS. THE FULL BOARD THEN VOTES TO APPROVE OR DISAPPROVE THE NEW POSITION. FORM 990, PART VI, SECTION A, LINE 7B MEMBERS OF THE BOARD OF DIRECTORS MUST APPROVE ANY BYLAW CHANGES. FORM 990, PART VI, SECTION B, LINE 11B THE 990 IS REVIEWED BY THE CFO AND CEO PRIOR TO FILING. THE FILED 990 IS THEN SHARED WITH THE FINANCE COMMITTEE AND REVIEWED IN DETAIL. A COPY OF THE 990 IS ISSUED TO EACH MEMBER OF THE BOARD AS WELL. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY IS REVIEWED EVERY YEAR BY THE POLICY AND PROCEDURE COMMITTEE AND BY THE CEO. OFFICERS AND DIRECTORS ARE REQUIRED TO REVIEW THE POLICY AND DISCLOSE CONFLICTS. THE CEO REVIEWS THE SIGNED STATEMENTS. IF THERE IS A CONFLICT, THE CONFLICT WOULD BE DECLARED, AND THE MEMBER WOULD ABSTAIN FROM VOTING. FORM 990, PART VI, SECTION B, LINE 15A THE HEALTH SYSTEM RELAYS ON MARKET COMPARABLE SALARY DATA TO SET THE RANGE OF COMPENSATION FOR THE CEO POSITION. THE RANGES ARE ADJUSTED AND REVIEWED ANNUALLY BY THE BOARD'S COMPENSATION COMMITTEE, WITH FINAL APPROVAL BY THE SYSTEM BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION BELIEVES THE GOVERNING DOCUMENTS AND POLICIES ARE THE PROPERTY OF THE ORGANIZATION AND ARE NOT AVAILABLE FOR PUBLIC INSPECTION. THE AUDITED FINANCIAL STATEMENTS ARE NOW REQUIRED TO BE ATTACHED TO FORM 990. AUDITED FINANCIAL INFORMATION IS POSTED ANNUALLY ON THE HOSPITAL'S WEBSITE. FORM 990, PART VII, SECTION A PURSUANT TO IRS FORM 990 INSTRUCTIONS, THIS SHORT PERIOD RETURN COVERS THE DATES 01/01/2023 THROUGH 09/30/2023 AND THERE IS NO CALENDAR YEAR ENDING WITHIN THE PERIOD AND THUS NO REPORTABLE COMPENSATION. FORM 990, PART IX, LINE 11G EMERGENCY ROOM SERVICE FEES: PROGRAM SERVICE EXPENSES 2,333,755. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,333,755. ANESTHESIA SERVICE FEES: PROGRAM SERVICE EXPENSES 291,627. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 291,627. LABORATORY SERVICE FEES: PROGRAM SERVICE EXPENSES 602,671. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 602,671. PHARMACY SERVICE FEES: PROGRAM SERVICE EXPENSES 28,311. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 28,311. FAMILY MEDICINE SERVICE FEES: PROGRAM SERVICE EXPENSES 698,808. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 698,808. OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 1,958,195. MANAGEMENT AND GENERAL EXPENSES 1,195,769. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,153,964. FORM 990, PART IV, LINE 12B AND PART XIII, LINE 2: THE ORGANIZATION WAS INCLUDED IN A SHORT YEAR CONSOLIDATED AUDIT FOR THE 10-MONTH PERIOD DECEMBER 1, 2022 THROUGH SEPTEMBER 30, 2023. THE ANSWERS FOR PART IV, LINE 12B AND PART XII, LINES 2A-2C HAVE BEEN ANSWERED YES EVEN THOUGH THE FORM 990 COVERS THE 9-MONTH PERIOD JANUARY 1, 2023 THROUGH SEPTEMBER 30, 2023. THE REASON FOR THIS CHANGE IS DUE TO A MERGER WITH THE BELLIN GUNDERSEN HEALTH SYSTEM. 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