2020-04-04T10:37:19-05:00 2019-06-30 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2018-07-01 390831153 CUMBERLAND MEMORIAL HOSPITAL D/B/A CUMBERLAND HEALTHCARE CUMB 7158222741 1110 7TH AVENUE CUMBERLAND WI 54829 MICHAEL GUTSCH CEO 7158222741 2020-04-03 1 MICHAEL J PETERSON CPA P01833529 2187224705 2020-04-03 71.13.38.61 2020-04-03 10:56:54 CD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 9747BB8E0DC0E78824B7C9EDF76D609BB7F00C05 2018 2021-01-29 14:40:06Z MICHAEL GUTSCH 1110 7TH AVENUE CUMBERLAND WI 54829 25090625 0 X WWW.CUMBERLANDHEALTHCARE.COM X 1955 WI PROVIDE EXCEPTIONAL QUALITY CARE, EVERY STEP OF THE WAY. 7 7 269 98 32710 -9404 91730 59568 26555380 24969040 72996 41594 16951 2904 26737057 25073106 0 0 0 0 14296683 14674818 0 0 0 11330192 10817182 25626875 25492000 1110182 -418894 21675038 20452067 6842473 5925814 14832565 14526253 X TO BE AN INDEPENDENT, COMMUNITY-BASED HEALTH SYSTEM DEDICATED TO PROVIDING EXCEPTIONAL QUALITY CARE, EVERY STEP OF THE WAY. 0 0 20592553 24880281 CUMBERLAND MEMORIAL HOSPITAL D/B/A CUMBERLAND HEALTHCARE (THE ORGANIZATION") IS AN INDEPENDENT, NONPROFIT, COMMUNITY-BASED RESIDENTIAL FACILITY THAT SERVES NORTHWEST WISCONSIN. THE ORGANIZATION OPERATES A HOSPITAL (CUMBERLAND MEMORIAL HOSPITAL) AND TWO CLINICS (LOCATED IN CUMBERLAND AND TURTLE LAKE). CUMBERLAND MEMORIAL HOSPITAL BECAME A CRITICAL ACCESS HOSPITAL ON AUGUST 19, 2005, LICENSED FOR 25 ACUTE CARE BEDS, INCLUDING 3 IN THE BIRTHPLACE. SERVICES INCLUDE, BUT ARE NOT LIMITED TO, THERAPY, WOUND CARE, CHEMOTHERAPY, OBSTETRICS, AND GENERAL SURGERY. DURING FISCAL YEAR 2019, ACUTE CARE DAYS TOTALED 1,249, SWING BED DAYS TOTALED 875, AND NEWBORN DAYS TOTALED 54. THE ORGANIZATION PROVIDED 23 INPATIENT AND 274 OUTPATIENT SURGERIES ALONG WITH 287 SCOPE PROCEDURES. THERE WERE ALSO 2,576 EMERGENCY ROOM VISITS. CUMBERLAND CLINIC TOTAL VISITS WERE 16,652 AND TURTLE LAKE WERE 3,588. 20592553 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 36 0 269 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X ANGIE MARTENS 7158222741 1110 7TH AVENUE CUMBERLAND WI 54829 JOSEPH LESCHISIN TRUSTEE 1.00 X 1800 0 0 THOMAS LINGEN MD TRUSTEE 1.00 X 2000 0 0 JENNIFER TURCOTT TRUSTEE 1.00 X 2000 0 0 MATT GORES CHAIRPERSON 1.00 X 2725 0 0 CANDACE COTONE VICE CHAIR 1.00 X X 2000 0 0 MARTIN PETERS TREASURER 1.00 X X 2000 0 0 ANN HENDRICKS SECRETARY 1.00 X X 3025 0 0 MICHAEL GUTSCH CEO 40.00 X 257054 0 41422 ANGIE MARTENS CFO 40.00 X 144152 0 7930 GARY DEGERMAN PHYSICIAN 40.00 X 248984 0 41180 DONALD FULLERTON CRNA 20.00 X 234436 0 50866 STEFANIE RINEHARDT CRNA 20.00 X 153372 0 42361 BENJAMIN BRENNA DIRECTOR OF REHAB 40.00 X 141759 0 44635 ROBERT LINDBERG COO 40.00 X 139421 0 33428 1334728 0 261822 16 0 1 0 CUMBERLAND CLINIC 1110 7TH AVENUE CUMBERLAND WI 54829 PHYSICIAN SERVICES 1945270 SHARED MEDICAL TECH 2020 W NEWTON ST RICE LAKE WI 54868 US, NUC MED, MRI 418295 MEDICAL SOLUTIONS 1010N 102ND ST SUITE 300 OMAHA NE 68114 POOL STAFF 141538 XTEND HEALTHCARE 90 VOLUNTEER DRIVE SUITE 150 HENDERSONVILLE TN 37075 FOLLOW UP BILLING/LEGACY SYSTEM 133367 4 22748 36820 59568 PATIENT SERVICE REVENUE 621990 24590424 24590424 NURSING HOME REVENUE 623000 210000 210000 168616 79857 32710 56049 24969040 47821 47821 1733 7960 -6227 -6227 -6227 12463 22748 9559 2904 2904 25073106 24880281 32710 100547 X 469000 3150 465850 10663408 9239023 1424385 235408 206583 28825 2529284 2119676 409608 777718 644635 133083 42468 42468 61154 61154 4854656 4118839 735817 119369 1700 117669 569303 433072 136231 849041 849041 424923 390975 33948 56074 38735 17339 1148886 899442 249444 109838 109838 MEDICAL SUPPLIES 898717 898717 PHARMACEUTICALS 748510 748510 PROVISION FOR BAD DEBTS 348329 348329 REPAIRS & MAINTENACE 245031 227882 17149 340883 273285 67598 25492000 20592553 4899447 0 1118393 399084 2784979 936634 3649838 5613828 88693 66191 462046 581220 51346 75829 27447350 17952640 9836744 9494710 3582999 3167832 100000 116739 21675038 20452067 2182131 2357662 17500 1916120 1654298 2034990 1680500 691732 233354 6842473 5925814 X 14832565 14526253 14832565 14526253 21675038 20452067 -418894 112582 0 X X 0 1 X 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3492 3492 0 PART II-B, LINE 1: CUMBERLAND MEMORIAL HOSPITAL (THE ORGANIZATION") PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THESE DUES ARE PRIMARILY FOR ACCESS TO EDUCATIONAL MATERIALS AND STAFF TRAINING AND DEVELOPMENT. A PORTION OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTH CARE ENVIRONMENT. THE ORGANIZATION IS ALSO A MEMBER OF THE RURAL WISCONSIN HEALTH COOPERATIVE (RWHC). EACH YEAR, THE ORGANIZATION PAYS MEMBERSHIP FEES TO THE RWHC. RWHC PROVIDES SUPPORT SERVICES FOR A NUMBER OF ITS MEMBER HOSPITALS THROUGHOUT THE STATE OF WISCONSIN. SOME OF THE MANY SERVICES PROVIDED TO MEMBER HOSPITALS INCLUDE PROVIDING ASSISTANCE TO ORGANIZATIONS IN FINDING GRANT FUNDING FOR NEW PROGRAMS, LEGAL SERVICES, REIMBURSEMENT REVIEW SERVICES, ACCOUNTING ASSISTANCE, CONTRACTING FOR THERAPIST AND EMERGENCY ROOM PATIENT CARE COVERAGE, AND ADMINISTRATIVE CONSULTING SERVICES. AS A PART OF THESE SERVICES, THE RWHC ALSO DOES PROVIDE ANALYSIS ON CURRENT HEALTH CARE ISSUES IN AN EFFORT TO PROMOTE AND BETTER HEALTH CARE FOR HOSPITALS IN RURAL COMMUNITIES THROUGHOUT WISCONSIN. ONE OF THESE EFFORTS ALSO INCLUDES SOME LOBBYING ON THE PART OF THE MEMBER ORGANIZATIONS. A PORTION OF THE FEES PAID BY THE ORGANIZATION IN FY2017 WERE RELATED TO LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE HEALTH CARE ENVIRONMENT IN THE STATE OF WISCONSIN. 0 956803 956803 13885335 9711764 4173571 1733385 102554 1630831 10178385 8138322 2040063 693442 693442 9494710 CAPITAL LEASE OBLIGATIONS 191615 THIRD-PARTY PAYABLES 41739 233354 X 24734336 9559 9559 24724777 348329 348329 25073106 25153230 9559 9559 25143671 348329 348329 25492000 PART X, LINE 2: THE ORGANIZATION IS A NONPROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE "CODE") AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE ORGANIZATION IS ALSO EXEMPT FROM STATE INCOME TAXES ON RELATED INCOME PURSUANT TO SIMILAR STATE OF WISCONSIN TAX LAWS. THE ORGANIZATION IS ALSO ENGAGED, TO A LIMITED EXTENT, IN CERTAIN ACTIVITIES SUBJECT TO TAXATION AS UNRELATED BUSINESS INCOME (UBI). UBI IS NOT SIGNIFICANT. PART XI, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EVENT 9,559. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS NET AGAINST REVENUE 348,329. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EVENT 9,559. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS NET AGAINST REVENUE 348,329. GOLF OUTING 23180 19748 3432 600 4210 370 PROGRESSIVE DINNER 12031 3000 9031 175 3898 306 35211 22748 12463 600 175 8108 676 9559 2904 1 1 X 1 X 1 X 1 1 0 1 1 69593 69593 0.00280 2522576 1194137 1328439 0.05280 2592169 1194137 1398032 0.05560 81259 81259 0.00320 48070 48070 0.00190 5482479 3670692 1811787 0.07210 3572 3572 0.00010 5615380 3670692 1944688 0.07730 8207549 4864829 3342720 0.13290 2504 2504 0.00010 2504 2504 0.00010 0 195064 39013 9761806 9814032 -52226 X 1 1 1 1 CUMBERLAND MEMORIAL HOSPITAL 1110 7TH AVENUE CUMBERLAND WI 54829 SEE SCHEDULE H PART V SUPPLEMENTAL 1058 X X X X AMBULANCE SERVICE; RURAL HEALTH CLINICS CUMBERLAND MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 18 1 1 1 1 X SEE SCHEDULE H PART V SUPPLEMENTAL X X 1 18 1 SEE SCHEDULE H PART V SUPPLEMENTAL 0 1 X 100.000000000000 300.000000000000 X X X X 1 1 X X X X 1 X SEE SCHEDULE H PART V SUPPLEMENTAL X SEE SCHEDULE H PART V SUPPLEMENTAL X SCH H PART V SUPPLEMENTAL X X X X X X 1 X 0 X X X 1 X 0 0 CUMBERLAND MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: THE 2018 CHNA WAS COMPLETED THROUGH THRIVE BARRON COUNTY, WHICH BRINGS ALL LOCAL COMPETING HEALTHCARE SYSTEMS TOGETHER AND THE BARRON COUNTY DEPARTMENT OF HEALTH & HUMAN SERVICES. OVER 800 SURVEYS WERE SENT OUT ELECTRONICALLY AND IN-PERSON TO BARRON COUNTY RESIDENTS ASKING THEM ABOUT WHAT THEY THOUGHT OUR TOP HEALTH CONCERNS WERE. ONCE THE VOTES WERE TALLIED, THE THRIVE BARRON COUNTY STEERING COMMITTEE MET TO DETERMINE THE HEALTH CONCERNS MOVING FORWARD. THERE WAS ALSO A PUBLIC FORUM AND PRESENTATIONS HELD IN SEPTEMBER FOR THE PUBLIC TO ATTEND AND BECOME INFORMED OF HEALTH CONCERNS AND VOICE ANY CONCERNS THEY HAD. CUMBERLAND MEMORIAL HOSPITAL PART V, SECTION B, LINE 6A: 2018 CHNA WAS DONE WITH THE FOLLOWING FACILITIES; AMERY REGIONAL MEDICAL CENTER, BARRON COUNTY AGING & DISABILITY RESOURCE CENTER, CUMBERLAND MEMORIAL HOSPITAL, MAYO CLINIC HEALTH SYSTEM AND MARSHFIELD CLINIC HEALTH SYSTEM, BARRON COUNTY PUBLIC HEALTH. CUMBERLAND MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: CUMBERLAND MEMORIAL HOSPITAL WORKED WITH BARRON COUNTY PUBLIC HEALTH (BARRON, WI) TO IDENTIFY AND PRIORITIZE HEALTH NEEDS. CUMBERLAND MEMORIAL HOSPITAL PART V, SECTION B, LINE 7D: SENT TO THRIVE AT BARRON COUNTY AND THEY ALSO DISTRIBUTE AND HAVE THEM AVAILABLE CUMBERLAND MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: BARRON COUNTY HAS CREATED A GROUP CALLED THRIVE BARRON COUNTY, WHICH IS MADE UP OF HEALTHCARE FACILITIES IN THE COUNTY, INCLUDING CUMBERLAND MEMORIAL HOSPITAL. TOGETHER THRIVE BARRON COUNTY CONDUCTED A CHNA AND SINCE THEN EACH YEAR A NEW ASSESSMENT WAS DONE. IN 2018, THE TOP THREE HEALTH CONCERNS WERE ALCOHOL, TOBACCO AND OTHER DRUG ABUSE (ATODA), MENTAL HEALTH AND CHRONIC DISEASE. GROUPS CALLED CHATS (COMMUNITY HEALTH ACTION TEAMS) WERE FORMED TO ADDRESS THE NEEDS IDENTIFIED AND SINCE 2012 HAVE BEEN WORKING TO BETTER SERVE THE NEEDS OF THE COUNTY RESIDENTS. ADDITIONALLY, CUMBERLAND MEMORIAL HOSPITAL ANNUALLY HOLDS THE "KNOW YOUR NUMBERS" HEALTH FAIR WHICH PROVIDES FREE SCREENINGS TO AREA RESIDENTS THAT COULD POTENTIALLY ADDRESS MAJOR MEDICAL CONCERNS.AS WITH ALL HEALTHCARE ORGANIZATIONS, ADEQUATE RESOURCES ARE NOT AVAILABLE TO ADDRESS EVERY UNMET HEALTH NEED IN THE COMMUNITIES CUMBERLAND MEMORIAL HOSPITAL SERVES. THERE WERE ITEMS IDENTIFIED IN THE CHNA WHICH WERE NOT ADDRESSED, HOWEVER, ALL ITEMS WERE CONSIDERED IF A NEED WAS BROUGHT TO THE ATTENTION OF THE STEERING COMMITTEE DURING THE INFORMATION GATHERING PHASE OF THE CHNA PROCESS. SEVERAL OF THE ITEMS WHICH WERE NOT ADDRESSED PRIMARILY WERE NOT ADDRESSED DUE TO THE FINANCIAL CONSTRAINT OF PROVIDING A NEW SERVICE FOR A LIMITED POPULATION OF PEOPLE. OVER THE NEXT THREE YEARS, CUMBERLAND MEMORIAL HOSPITAL WILL CONTINUE TO PLAY A LEADING ROLE IN ADDRESSING THE HEALTH NEEDS OF THOSE WITHIN THE COMMUNITY, CONGRUENT WITH THE HOSPITAL'S MISSION. CUMBERLAND MEMORIAL HOSPITAL PART V, SECTION B, LINE 16J: THE FINANCIAL ASSISTANCE POLICY IS AVAILABLE THROUGH THE BUSINESS OFFICE STAFF. PATIENTS ARE ENCOURAGED TO CONTACT A FINANCIAL COUNSELOR FOR FURTHER INFORMATION ON THE FINANCIAL ASSISTANCE POLICY. THE HOSPITAL'S WEBSITE ALSO ENCOURAGES PATIENTS TO INQUIRE ABOUT THE FINANCIAL ASSISTANCE POLICY. PART V, LINE 7A: HOSPITAL FACILITIES WEBSITE: CUMBERLANDHEALTHCARE.COM/PATIENTS-VISITORS/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ PART V, LINE 10A: HOSPITAL FACILITY'S MOST RECENTLY ADOPTED IMPLEMENTATION STRATEGY IS POSTED ON THEIR WEBSITE: CUMBERLANDHEALTHCARE.COM/PATIENTS-VISITORS/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ PART V, LINE 16A, B, C: THE FAP WAS WIDELY AVAILABLE ON A WEBSITE: HTTPS://CUMBERLANDHEALTHCARE.COM/PATIENTS-VISITORS/PATIENT-FINANCIAL-SERVICES/THE FAP APPLICATION FORM WAS WIDELY AVAILABLE ON A WEBSITE: HTTPS://CUMBERLANDHEALTHCARE.COM/PATIENTS-VISITORS/PATIENT-FINANCIAL-SERVICES/A PLAIN LANGUAGE SUMMARY OF THE FAP WAS WIDELY AVAILABLE ON A WEBSITE: HTTPS://CUMBERLANDHEALTHCARE.COM/PATIENTS-VISITORS/PATIENT-FINANCIAL-SERVICES/ 2 2 - CUMBERLAND HEALTHCARE MEDICAL CLINIC 1110 7TH AVENUE CUMBERLAND WI 54829 RURAL HEALTH CLINIC 4 - CUMBERLAND HEALTHCARE TURTLE LAKE CENTER 632 US HWY 8 TURTLE LAKE WI 54889 RURAL HEALTH CLINIC PART I, LINE 7: THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST-TO-CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES, EXCLUDING THE PROVISION FOR BAD DEBTS DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST-TO-CHARGE RATIO IS APPLIED AGAINST HOSPITAL REVENUE AND EXPENSE CATEGORIES TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER IRS SUGGESTED COSTING METHODS FOR THE FORM 990. THE COSTING METHODOLOGY USED IS BASED ON MEDICARE COST REPORTING METHODS. PART I, LINE 7G: THE COST OF SUBSIDIZED SERVICES IS BASED ON COST ALLOCATIONS FROM THE MEDICARE COST REPORT. ALLOWABLE COSTS ARE ASSIGNED DIRECTLY TO DEPARTMENTS THROUGHOUT THE YEAR AND THEN THE COST REPORT USES THE ALLOCATION METHODOLOGY TO ASSIGN ALL OTHER COSTS TO CALCULATE SERVICE LINE COSTS. SUBSIDIZED HEALTH SERVICES INCLUDED THE CLINICS AND THE EMERGENCY ROOM DEPARTMENT. THESE SERVICES ARE UNAVAILABLE TO MEMBERS OF THE COMMUNITY OTHER THAN THROUGH CUMBERLAND MEMORIAL HOSPITAL. IT HAS BEEN THE GOAL OF CUMBERLAND MEMORIAL HOSPITAL TO PROVIDE THESE SERVICES TO THE COMMUNITY REGARDLESS OF A PATIENT'S ABILITY TO PAY. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 348,329. PART II, COMMUNITY BUILDING ACTIVITIES: CUMBERLAND MEMORIAL HOSPITAL PROVIDES SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS AND IN ADDITION, THE HOSPITAL BELIEVES THAT IT PROVIDES A CRITICALLY IMPORTANT COMMUNITY BENEFIT WHICH IS NOT QUANTIFIED. SEE PART 1, LINE 7 FOR THE CALCULATED COST OF PROVIDING COMMUNITY SERVICES. CUMBERLAND MEMORIAL HOSPITAL, LIKE MOST RURAL HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY WHICH WITHOUT THE HOSPITAL WOULD NOT BE AVAILABLE LOCALLY. BEYOND INPATIENT HOSPITALIZATIONS, THE HOSPITAL PROVIDES LOCAL ACCESS TO MANY HEALTH SERVICES: AMBULANCE SERVICES, BIRTHING CENTER, DIAGNOSTICS, EMERGENCY SERVICES & URGENT CARE, EXTENDED CARE, INPATIENT CARE, LABORATORY SERVICES, OCCUPATIONAL HEALTH, REHABILITATION SERVICES, SPECIALTY MEDICINE, SLEEP CENTER, SPEECH, AND SURGICAL SERVICES. PART III, LINE 2: THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST-TO-CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES, EXCLUDING THE PROVISION FOR BAD DEBTS, DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST-TO-CHARGE RATIO IS APPLIED AGAINST THE TOTAL CHARGES THAT ARE WRITTEN OFF DURING THE FISCAL YEAR TO ESTIMATE THE COST OF THE CARE OF PATIENTS THAT HAVE ACCOUNTS THAT ARE DEEMED TO BE BAD DEBTS TO THE HOSPITAL. THE HOSPITAL ALSO PROVIDES DISCOUNTS TO ELIGIBLE UNINSURED OR UNDERINSURED PATIENTS UNDER ITS CHARITABLE CARE POLICY. THESE AMOUNTS ARE INCLUDED IN THE CONTRACTUAL ADJUSTMENTS ON THE FINANCIAL STATEMENTS AND ARE NOT INCLUDED IN THE RATIO AS DESCRIBED ABOVE AND APPROVED BY THE IRS FOR USE ON FORM 990. IF CONSIDERED, THESE ADDITIONAL WRITE-OFF AMOUNTS TO UNINSURED OR UNDERINSURED ACCOUNTS WOULD ALSO INCREASE THE ESTIMATED BAD DEBT EXPENSE AMOUNT ASSOCIATED WITH THESE UNCOLLECTIBLE ACCOUNTS TO THE HOSPITAL. PART III, LINE 3: MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER THE HOSPITAL HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO ACCOUNTS RECEIVABLE. MANY TIMES PATIENTS ARE UNABLE TO COMPLETE THE REQUIRED CHARITY CARE APPLICATION AND ARE TRANSFERRED TO COLLECTION SERVICES EVEN THOUGH THE HOSPITAL PROVIDES THIS INFORMATION TO ALL PATIENTS AND ASSISTANCE WITH THE APPLICATIONS. DUE TO NO RESPONSES FROM SOME PATIENTS, A SMALL AMOUNT OF BAD DEBTS COULD BE CONSIDERED AS CHARITY CARE. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE AND CREDIT POLICY: 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 DOUBTFUL 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 DOUBTFUL 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 UNCOLLECTIBLE AMOUNTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET BEEN PAID, OR FOR PAYORS AND PATIENTS 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 ON THE BASIS OF ITS PAST 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 ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE AUDITED FINANCIAL STATEMENTS DO NOT INCLUDE A SEPARATE FOOTNOTE REGARDING BAD DEBT EXPENSE. PART III, LINE 8: CUMBERLAND MEMORIAL HOSPITAL IS DESIGNATED A CRITICAL ACCESS HOSPITAL AND AS SUCH A PORTION OF ITS REVENUE IS PAID UNDER A COST REIMBURSEMENT SYSTEM. BASED ON THE INSTRUCTIONS, THE TOTAL MEDICARE REVENUE SHOWN ON THIS FORM 990 INCLUDES ONLY A PORTION OF THE GROSS MEDICARE REVENUE THAT IS ACTUALLY RECEIVED BY THE HOSPITAL FROM THE MEDICARE PROGRAM. THE AMOUNTS LISTED FOR MEDICARE DO NOT INCLUDE PHYSICIAN AND MID-LEVEL PRACTITIONER SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT CUMBERLAND MEMORIAL HOSPITAL OR AMBULANCE SERVICES. PHYSICIAN COVERAGE IS REIMBURSED PRIMARILY ON A FEE SCHEDULE REIMBURSEMENT METHODOLOGY AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY AND AMBULANCE 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 CUMBERLAND MEMORIAL HOSPITAL PROVIDES TO THE COMMUNITY AND SURROUNDING AREA OF CUMBERLAND, WISCONSIN. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON AN OVERALL AVERAGE COST TO CHARGE RATIO 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) DIVIDED BY TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT EXPENSE. THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES WHICH ARE REIMBURSED ON A COST METHODOLOGY EXCLUDING THE FEE SCHEDULE ITEMS LIKE PHYSICIAN AND MID-LEVEL PRACTITIONER SERVICES WHICH THE HOSPITAL WOULD SHOW A LARGE LOSS ON THESE SERVICES. 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 HEALTH CARE 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: UNDER THE HOSPITAL'S COLLECTION AND CHARITABLE CARE POLICIES, CUMBERLAND MEMORIAL HOSPITAL MAKES EVERY ATTEMPT TO IDENTIFY AND PROMOTE CHARITY CARE TO PATIENTS. INCLUDED IN THE HOSPITAL'S CHARITABLE CARE POLICY IT IS NOTED THAT PATIENTS MAY QUALIFY FOR CHARITY CARE EITHER PRIOR TO ADMISSION OR FOLLOWING DISCHARGE. ALL INPATIENT SELF-PAY ADMISSIONS ARE SCREENED BY THE HOSPITAL'S FINANCIAL COUNSELOR TO ALLOW THESE PATIENTS THE ABILITY TO COMPLETE THEIR APPLICATION DURING THEIR STAY AT THE HOSPITAL, DEPENDING UPON THE PATIENT'S CONDITION, THE PATIENT'S RESPONSIBLE PARTY MAY BE CONTACTED TO COMPELTE AND RETURN THE FORMS AT A LATER TIME WHEN THEIR CARE ALLOWS THIS COMPLETION. DURING THE PATIENT ACCOUNT COLLECTION PROCESS, SELF-PAY PATIENTS ARE ALSO INFORMED OF THE HOSPITAL'S COLLECTION POLICES AS WELL AS THE CHARITY AND COMMUNITY CARE PROGRAM TO ALLOW PATENTS THE OPPORTUNITY TO COMPLETE THE APPROPRIATE FORMS AND QUALIFY UNDER THE PROGRAM. INCLUDED IN THE POLICY, IT IS ALSO NOTED THAT THE HOSPITAL RESERVES THE RIGHT TO MAKE OR GRANT ADDITIONAL CHARITY CARE ON A CASE-BY-CASE BASIS. PART VI, LINE 2: THE HOSPITAL ASSESSES THE NEEDS OF THE COMMUNITY THROUGH SURVEYS AND BY RECOGNIZING WHY CERTAIN PATIENTS ARE REFERRED OUT OF THE AREA. THE HOSPITAL THEN ATTEMPTS TO GET SPECIALISTS IN THE IDENTIFIED AREAS INTO THE HOSPITAL TO SEE PATIENTS AND MEET THEIR NEEDS. JULY 2015 WE OPENED AN ONCOLOGY UNIT AFTER RECOGNIZING A NEED AND WANT FOR PATIENTS TO RECEIVE TREATMENT CLOSE TO HOME. WE ALSO RECOGNIZE A GROWING NEED FOR DIABETIC EDUCATION. BECAUSE THE RECOGNIZED NEED FOR MENTAL HEALTH, WE HIRED A MENTAL HEALTH COUNSELOR AT THE END OF THE FY16. SMOKING CESSATION CLASSES HAVE ALSO BEEN HELD THROUGHOUT THE YEAR. IN FY 2017 DIABETIC EDUCATION CLASSES WERE ADDED. LOOKING TO ADD ENT SPECIALIST SO WE CAN SERVE THAT NEED AND PATIENTS DON'T HAVE TO TRAVEL OUT OF THE AREA. WE LOOK FOR OPPORTUNITIES TO WORK WITH THE SCHOOL AND SERVE THE NEEDS TO STUDENTS AND BRING SERVICES TO THEM RATHER THAN THEIR PARENTS HAVING TO LEAVE THEIR JOBS TO BRING STUDENTS TO APPOINTMENTS AT OUR FACILITY. WE ARE LOOKING TO EXPAND OUR MENTAL HEALTH SERVICES AND HAVE JUST HIRED A PSYCH NP. WE ARE WORKING TO OFFER TELEHEALTH SERVICES. PART VI, LINE 3: IF A PATIENT IS IDENTIFIED AS UNINSURED, HOSPITAL STAFF WORKS WITH THE PATIENT OR THEIR FAMILY TO DETERMINE IF THEY ARE ELIGIBLE FOR ANY TYPE OF GOVERNMENT PROGRAMS OR QUALIFY FOR THE HOSPITAL'S CHARITY CARE PROGRAM. ASSISTANCE INFORMATION IS ALSO PUBLICIZED ON OUR WEBSITE PART VI, LINE 4: THE HOSPITAL SERVES THE COMMUNITIES OF CUMBERLAND, TURTLE LAKE, AND ALMENA, WI AND SURROUNDING COMMUNITIES WITHIN A 20 MILE RADIUS. THERE ARE THREE OTHER HOSPITALS LOCATED IN THE RURAL AREA THAT THE ORGANIZATION SERVES. WE ALSO HAVE A SATELLITE CLINIC IN TURTLE LAKE WHICH OFFERS FAMILY PRACTICE AND REHAB SERVICES PART VI, LINE 5: A MAJORITY OF OUR ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA. OUR ORGANIZATION EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY FOR SOME OR ALL OF ITS DEPARTMENTS. WE ALSO PARTICIPATE IN COMMUNITY HEALTH FAIRS AND PROVIDE SERVICE AT SPORTING EVENTS. SURPLUS FUNDS ARE INVESTED BACK INTO THE FACILITY AND ITS EQUIPMENT TO ENSURE THE NEEDED SERVICES ARE CONTINUED TO BE PROVIDED IN THIS COMMUNITY. PART VI, LINE 7, REPORTS FILED WITH STATES WI X X X 0 0 0 0 0 0 0 0 0 MICHAEL GUTSCH CEO 218619 0 30301 0 8134 0 7829 0 33593 0 298476 0 0 0 ANGIE MARTENS CFO 138214 0 5938 0 0 0 5767 0 2163 0 152082 0 0 0 GARY DEGERMAN PHYSICIAN 248984 0 0 0 0 0 7587 0 33593 0 290164 0 0 0 DONALD FULLERTON CRNA 234436 0 0 0 0 0 9813 0 41053 0 285302 0 0 0 STEFANIE RINEHARDT CRNA 153372 0 0 0 0 0 1412 0 40949 0 195733 0 0 0 BENJAMIN BRENNA DIRECTOR OF REHAB 132394 0 4086 0 5279 0 4550 0 40085 0 186394 0 0 0 ROBERT LINDBERG COO 133083 0 6338 0 0 0 0 0 33428 0 172849 0 0 0 A WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 2014-10-28 2925000 REFUND PRIOR ISSUE 0 0 0 A 1200000 2925000 58500 352739 2513761 2009 0 1 1 1 A 0 0 0 0 0 0 1 A 0 1 0 0 0 0 0 0 1 A 1 FORM 990, PART VI, SECTION B, LINE 11B THE RETURN IS REVIEWED BY THE CHIEF FINANCIAL OFFICER AND A FINAL DRAFT IS GIVEN TO THE BOARD MEMBERS OF CUMBERLAND MEMORIAL HOSPITAL. UPON APPROVAL FROM THE BOARD MEMBERS, THE RETURN IS FILED WITH THE INTERNAL REVENUE SERVICE (IRS). FORM 990, PART VI, SECTION B, LINE 12C CUMBERLAND MEMORIAL HOSPITAL REQUIRES ITS BOARD MEMBERS TO SIGN A CONFLICT OF INTEREST STATEMENT ANNUALLY. OFFICERS AND KEY EMPLOYEES OF CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. SIGN A CODE OF CONDUCT STATEMENT. IN THE CODE OF CONDUCT STATEMENT IT MENTIONS THE CONFLICT OF INTEREST. ANY PERSON THAT BELIEVES TO HAVE A CONFLICT SHOULD DISCLOSE AS A MATTER OF RECORD TO THE BOARD ON AN ANNUAL BASIS OR AS THE INTEREST DEVELOPS AND BEFORE IT IS CONSUMMATED. ANY DIRECTOR HAVING A CONFLICT MAY NOT VOTE OR USE PERSONAL INFLUENCE ON THE MATTER. THE DIRECTOR CAN STATE THEIR POSITION ON THE MATTER BEFORE ABSTAINING FROM VOTE. FORM 990, PART VI, SECTION B, LINE 15 EXECUTIVE SALARIES ARE SET ANNUALLY CONSIDERING COMPENSATION LEVELS AT SIMILARLY SITUATED ORGANIZATIONS (TYPICALLY NOT-FOR-PROFIT HEALTH CARE ORGANIZATIONS IN SIMILAR REVENUE CATEGORIES). THE BOARD OF DIRECTORS IS RESPONSIBLE FOR SETTING THE SALARY OF THE CEO AND CFO BASED ON THEIR JOB PERFORMANCE. THE BOARD RELIES UPON COMPARABILITY DATA DEVELOPED BY OUTSIDE CONSULTANTS TO SUPPORT ITS DECISION MAKING PROCESS AND TO ENSURE COMPETITIVE SALARY LEVELS. ALL OTHER NON-UNION WAGES ARE REVIEWED SEMI-ANNUALLY IN COMPARISON TO THE RURAL WISCONSIN HEALTH COOPERATIVE WAGE SURVEY. THIS WAGE SURVEY INCLUDES WAGE DATA OF 27 RURAL HEALTH CARE ORGANIZATIONS. THE GOAL OF THE ORGANIZATION IS TO REMAIN WITHIN THE WAGE SURVEY AVERAGES, BASED ON YEARS OF SERVICE TO BE COMPETITIVE WITH SIMILAR ORGANIZATIONS. FORM 990, PART VI, SECTION C, LINE 19 CUMBERLAND MEMORIAL HOSPITAL MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 846,306. MANAGEMENT AND GENERAL EXPENSES 735,817. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,582,123. CONTRACTED ER PHYSICIANS: PROGRAM SERVICE EXPENSES 858,221. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 858,221. CONTRACTED - PHARMACY: PROGRAM SERVICE EXPENSES 611,016. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 611,016. CONTRACTED RADIOLOGY/NUCLEAR MEDICINE SERVICES: PROGRAM SERVICE EXPENSES 414,101. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 414,101. CONTRACTED NURSING SERVICES: PROGRAM SERVICE EXPENSES 206,824. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 206,824. CONTRACTED PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 1,182,371. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,182,371. FORM 990, PART XII, LINE 2C, AUDIT OVERSIGHT: CUMBERLAND MEMORIAL HOSPITAL'S ENTIRE BOARD OF DIRECTORS IS RESPONSIBLE FOR THE FINANCIAL STATEMENT AUDIT AND SELECTION OF THE INDEPENDENT ACCOUNTANT. THE AUDITED FINANCIAL STATEMENTS ARE REVIEWED BY THE BOARD OF DIRECTORS ANNUALLY AND ANY QUESTIONS OR CONCERNS REGARDING THE STATEMENTS ARE ADDRESSED BY THE INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR.