2020-08-14T07:24:10-05:00 2019-09-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2018-10-01 061745397 OCONTO HOSPITAL AND MEDICAL CENTER BELLIN HEALTH OCONTO HOSPITAL OCON 9208351100 PO BOX 357 OCONTO WI 54153 JAMES DIETSCHE CEO 9208351100 2020-08-13 1 TERRI REXRODE CPA MST P00096513 9206620016 2020-08-13 184.97.211.65 2020-08-13 10:02:18 CD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 7D2FE2EA17AC540A2D29D4112E82844D375299C1 2018 2020-09-22 18:59:49Z BELLIN HEALTH OCONTO HOSPITAL LAURA CORMIER PO BOX 357 OCONTO WI 54153 57016078 0 X WWW.OCONTOHOSPITAL.ORG X 2005 WI OCONTO HOSPITAL & MEDICAL CENTER, INC. (THE ORGANIZATION) IS YOUR HOME TOWN HEALTHCARE SERVICE PROVIDER, CREATED TO MAKE OUTSTANDING HEALTHCARE CONVENIENT. BACKED BY THE RESOURCES OF BELLIN HEALTH, THE ORGANIZATION OFFERS OUTSTANDING HOSPITAL-BASED, EMERGENCY AND PRIMARY CARE SERVICES. THE ORGANIZATION OFFERS THE CARE YOU NEED WHERE YOU WANT IT. 7 3 294 8 0 0 8467 11996 45054893 56894851 671 1135 68158 55429 45132189 56963411 0 0 0 0 24388581 26980052 0 0 0 28549101 34701060 52937682 61681112 -7805493 -4717701 42967666 42446099 41953666 46104123 1014000 -3658024 X THE MISSION OF OCONTO HOSPITAL & MEDICAL CENTER IS TO PROVIDE 24-HOUR LOCAL ACCESS TO EFFECTIVE, EFFICIENT HEALTH, WELLNESS AND PREVENTATIVE SERVICES TO OCONTO AND THE SURROUNDING RURAL COMMUNITIES. TOWARD THIS PURPOSE, OCONTO HOSPITAL & MEDICAL CENTER WORKS IN PARTNERSHIP WITH THE COMMUNITY, THE CITIZENS HOSPITAL FOUNDATION AND BELLIN HEALTH. 0 0 15540207 17845911 AS A KEY REGIONAL ASSET, THE ORGANIZATION IS A NOT-FOR-PROFIT HEALTHCARE PROVIDER. THE ORGANIZATION PROVIDES ACUTE HOSPITAL, EMERGENCY AND URGENT CARE TO RESIDENTS OF OCONTO, WISCONSIN AND THE SURROUNDING COMMUNITIES. DURING THE PERIOD OF OCTOBER 1, 2018 TO SEPTEMBER 30, 2019, 346 INPATIENT DAYS WERE PROVIDED AND 221 SWING BED DAYS WERE PROVIDED. THE NUMBER OF OUTPATIENTS REGISTERED DURING THE SAME 12 MONTH PERIOD WAS 19,102. 38988676 38872299 IN 2018 THE OCONTO HOSPITAL & MEDICAL CENTER CORPORATION HAD A MULTISPECIALTY CLINIC IN MARINETTE WISCONSIN. SERVICES OFFERED AT THE MARINETTE LOCATION INCLUDE PRIMARY CARE SERVICES, RADIATION ONCOLOGY SERVICES, CHEMOTHERAPY AND INFUSION SERVICES. IN ADDITION THE ORGANIZATION HAS PRIMARY CARE CLINICS IN OCONTO, CRIVITZ AND PESHTIGO WISCONSIN, AND DAGGETT AND MENOMINEE MICHIGAN. THESE PROGRAM SERVICES PROVIDED 11,771 URGENT CARE VISITS, 84,598 PRIMARY CARE VISITS AND 25,011 SPECIALTY PROVIDER VISITS TO THESE COMMUNITIES DURING THE PERIOD OF OCTOBER 1,2018 TO SEPTEMBER 30, 2019. 54528883 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 0 0 294 1 0 0 0 0 0 0 0 0 0 0 0 0 X 7 3 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X SARA ARNDT 9204457260 2020 SOUTH WEBSTER AVENUE GREEN BAY WI 54301 GEORGE KERWIN - TERMED BOARD MEMBER 0.50 50.00 X 0 1082565 38477 SARA ARNDT BOARD MEMBER 0.50 40.00 X 0 76290 21685 LAURA HIEB BOARD MEMBER 0.50 50.00 X 0 325643 2795 DAVID HONISH CHAIRPERSON 0.50 X X 0 0 0 RODNEY JOHNSON SECRETARY/TREASURER 0.50 X X 0 0 0 LAURA CORMIER CEO 50.00 X X 159563 0 27423 CRAIG ALWIN BOARD MEMBER 0.50 X 0 0 0 JAMES DIETSCHE BOARD MEMBER 0.50 50.00 X 0 493837 25547 CHARLES HEYKA MD PRESIDENT OF MEDICAL STAFF 50.00 X 382286 0 33154 PAWNEET SING MD PHYSICIAN 50.00 X 577443 0 10090 CALVIN NOGLER MD PHYSICIAN 50.00 X 300510 0 26737 MICHAEL BRENNER MD PHYSICIAN 50.00 X 336734 0 19804 JAMES OPOIEN MD PHYSICIAN 50.00 X 288442 0 23669 JON SIMMONS MD PHYSICIAN 50.00 X 317559 0 14531 2362537 1978335 243912 35 0 1 0 THARIO CLEANING SERVICES INC 2936 HOLMGREN WAY GREEN BAY WI 54304 HOUSEKEEPING SERVICES 509727 COMPHEALTH MEDICAL STAFFING PO BOX 972670 DALLAS TX 75397 CONTRACTED URGENT CARE PROVIDER SERVICES 265738 MICHAEL DOWNS MD PO BOX 72062 CEDARBURG WI 53012 CONTRACTED ED PHYSICIAN SERVICES 251855 DAVID HOYER MD 2480 WHISTLING SWAN CT MENASHA WI 54952 CONTRACTED ED PHYSICIAN SERVICES 200077 RADIOLOGY ASSOCIATES OF APPLETON SC 2500 E CAPITAL DR APPLETON WI 54911 RADIATION ONCOLOGY PROVIDER SERVICES 169699 7 11996 11996 NET PATIENT REVENUE 621300 56585297 56585297 MISCELLANEOUS REVENUE 900099 189554 189554 RENT FROM AFFILIATES 900099 120000 120000 56894851 1135 1135 95183 52667 42516 42516 42516 INCENTIVE PAYMENTS 621110 12913 12913 12913 56963411 56718210 0 233205 602427 415441 186986 21908604 21438771 469833 907341 876341 31000 2226552 2199364 27188 1335128 1295979 39149 3910150 3776343 133807 41610 568 41042 370230 300830 69400 13262 13191 71 4548763 4546499 2264 309450 298253 11197 104205 100835 3370 1896098 1896098 3805599 3381677 423922 85350 31429 53921 SUPPLIES EXPENSE 14607021 10958175 3648846 EQUIPMENT RENT/MAINTENA 2884943 2879560 5383 BAD DEBT EXPENSE 1926711 1926711 DUES & SUBSCRIPTIONS 141054 83994 57060 56614 4922 51692 61681112 54528883 7152229 0 1922278 2768980 7110039 8791418 943712 851934 43451 18191 46419837 17664837 31199542 28755000 870622 501881 878022 758695 42967666 42446099 2883080 2316184 11236454 10782285 27834132 33005654 41953666 46104123 X 300980 -4416719 713020 758695 1014000 -3658024 42967666 42446099 X -4717701 45677 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 739879 739879 19013511 4889488 14124023 171971 154280 17691 26494476 12621069 13873407 28755000 DUE TO AFFILIATE 33005654 33005654 55089367 -1926711 -1926711 57016078 -52667 -52667 56963411 59807068 52667 52667 59754401 1926711 1926711 61681112 PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS -1,926,711. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL DEPRECIATION -52,667. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL DEPRECIATION 52,667. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 1,926,711. 1 1 X 1 X 220.000000000000 1 X 1 1 1 0 1 1 602118 602118 0.01010 8940244 5247869 3692375 0.06180 9542362 5247869 4294493 0.07190 8375 8375 0.00010 1519 1519 0.00000 3824 3824 0.00010 13718 13718 0.00020 9556080 5247869 4308211 0.07210 8 7211 7211 0.00010 3 100 1755 1755 0.00000 11 100 8966 8966 0.00010 1 1040423 9681301 8669215 1012086 X 1 1 1 1 OCONTO HOSPITAL & MEDICAL CENTER INC 820 ARBUTUS AVE OCONTO WI 54153 WWW.OCONTOHOSPITAL.ORG 1061 X X X X OCONTO HOSPITAL & MEDICAL CENTER INC 1 0 0 1 X X X X X X X X X 17 1 1 1 1 X SEE PART V, SECTION B, LINE 7D X SEE PART V, SECTION B, LINE 7D X 1 17 1 SEE PART V, SECTION B, LINE 7D 0 1 X 220.000000000000 400.000000000000 X X X 1 1 X X X X 1 X HTTPS://WWW.BELLIN.ORG/IMAGES/UPLOADS/BUSOF.001_-_FINANCIAL_ASSISTANCE.PDF X HTTPS://WWW.BELLIN.ORG/IMAGES/UPLOADS/COMMUNITY_CARE_APPLICATION.PDF X HTTPS://WWW.BELLIN.ORG/IMAGES/UPLOADS/PLAIN_LANGUAGE_SUMMARY_-_FINANCIAL_AS X X X X X X X 1 X 0 X X X X 1 X 0 0 OCONTO HOSPITAL & MEDICAL CENTER, INC. PART V, SECTION B, LINE 5: THIS YEAR'S ASSESSMENT BUILT ON COLLABORATION, ACTIVELY SEEKING INPUT FROM A BROAD CROSS SECTION OF COMMUNITY STAKEHOLDERS WITH THE GOAL OF REACHING CONSENSUS ON PRIORITIES TO MUTUALLY FOCUS HUMAN, MATERIAL AND FINANCIAL RESOURCES ON. BELOW IS A LISTING OF PARTICIPANTS IN A CHNA SUMMIT IN WHICH HEALTH PRIORITIES WERE DETERMINED.-CITY OF GREEN BAY - PARKS & RECREATION-NORTHEASTERN WISCONSIN TECHNICAL COLLEGE-CITY OF DE PERE - HEALTH DEPARTMENT-BELLIN HEALTH-BROWN COUNTY PUBLIC HEALTH-ASHWAUBENON SCHOOLS-INTERN SCHOOL SOCIAL WORKER (HSSD)-WILLOW CREEK BEHAVIORAL HEALTH-HSHS ST VINCENT HOSPITAL/ ST MARY'S HOSPITAL-LIVE 54218-BELLIN PSYCHIATRIC CENTER-BROWN COUNTY BOARD-WIC-FAMILY & CHILDCARE RESOURCES OF NEW-AGING AND DISABILITY RESOURCE CENTER-BROWN COUNTY BOARD OF HEALTH-WI DHS DIVISION OF PUBLIC HEALTH-HOWARD SUAMICO SCHOOLS-CONNECTIONS FOR MENTAL WELLNESS-PULASKI COMMUNITY SCHOOLS-ST NORBERT COLLEGE-HSHS LIBERTAS TREATMENT CENTER-SHERMAN COUNSELING-UW EXTENSIONS-AIDS RESOURCE CENTER OF WISCONSIN (ARCW)-FOUNDATIONS-BOCE/ETC.-AURORA BEHAVIORAL HEALTH - UWGB-UNITED WAY - BROWN COUNTY-EX PRISONER OPPORTUNITIES-INTEGRATED COMMUNITY SOLUTIONS-OCONTO COUNTY PUBLIC HEALTH-RETIRED LAW ENFORCEMENT - DE PERE-BELLIN COLLEGE-BROWN COUNTY - CTC-UW GREEN BAY-ONEIDA NATION-BROWN COUNTY CHILD AND ADOLESCENT BEHAVIORAL HEALTH-PREVEA HEALTH-BROWN COUNTY HEALTH & HUMAN SERVICES-NEW COMMUNITY CLINIC-NEW COMMUNITY CLINIC & BROWN COUNTY BOARD OF HEALTH-GREEN BAY AREA PUBLIC SCHOOLS-CITY OF GREEN BAY - MAYOR-AURORA BAYCARE MEDICAL CENTER (ABMC)-ORAL HEALTH PARTNERSHIP-COMMUNITY VOLUNTEER-CITY OF DE PERE-JOSHUA - BC MENTAL HEALTH TASK FORCE - CONNECTIONS FOR MENTAL WELLNESS-DIOCESE OF GB CATHOLIC CHARITIES-BAY AREA COMMUNITY COUNCIL (BACC)-DARJUNE/EXPOTO ENSURE THAT THE NEEDS OF THESE GROUPS WERE ADEQUATELY REPRESENTED, WE INCLUDED REPRESENTATIVES FROM BROWN COUNTY HEALTH AND HUMAN SERVICES (PUBLIC HEALTH, AGING & DISABILITY RESOURCE CENTER, AND CHILD & FAMILY SERVICES); VARIOUS BROWN COUNTY DEPARTMENTS INCLUDING HEAD START, PROBATION & PAROLE, VICTIM/WITNESS SERVICES, VETERANS SERVICES; LOVE, INC.; BROWN COUNTY INTERFAITH ORGANIZATION; LOCAL SCHOOL DISTRICTS; BROWN COUNTY INTERFAITH; PARTNERS FOR COMMUNITY DEVELOPMENT; FAMILY RESOURCE CENTER OF BROWN COUNTY; SAFE HARBOR. THESE ORGANIZATIONS SERVE THE UNDER-RESOURCED IN OUR COMMUNITY, INCLUDING LOW-INCOME SENIORS, CHILDREN LIVING IN POVERTY, FAMILIES WHO STRUGGLE WITH SHELTER AND FOOD INSECURITY; VETERANS AND VICTIMS OF DOMESTIC VIOLENCE. OCONTO HOSPITAL & MEDICAL CENTER, INC. PART V, SECTION B, LINE 6A: AURORA BAYCARE MEDICAL CENTER (GREEN BAY) AND ST. MARY'S AND ST. VINCENT HOSPITALS (HSHS, GREEN BAY) OCONTO HOSPITAL & MEDICAL CENTER, INC. PART V, SECTION B, LINE 6B: BROWN COUNTY HEALTH DEPARTMENT, CITY OF DE PERE HEALTH DEPARTMENT, AND BROWN COUNTY UNITED WAY. OCONTO HOSPITAL & MEDICAL CENTER, INC. PART V, SECTION B, LINE 7D: FULL URL FOR PART V, SECTION B, LINE 7A:HTTPS://WWW.BELLIN.ORG/IMAGES/UPLOADS/BROWN_COUNTY-FY2018_CHNA_EDITS_04_10_FULL URL FOR PART V, SECTION B, LINE 7B:HTTPS://WWW.CO.OCONTO.WI.US/DEPARTMENTS/PAGE_7389C0128C0F/?DEPARTMENT=AE781FULL URL FOR PART V, SECTION B, LINE 10A:HTTPS://WWW.BELLIN.ORG/IMAGES/UPLOADS/BROWN_COUNTY_FY2018_IMPLEMENTATION_PL OCONTO HOSPITAL & MEDICAL CENTER, INC. PART V, SECTION B, LINE 11: THE MOST RECENT CHNA IDENTIFIED COMMUNITY NEEDS FOR FISCAL YEARS 2018 THROUGH 2020. THE NEEDS IDENTIFIED ARE: MENTAL HEALTH, ALCOHOL AND OTHER DRUG ABUSE (AODA), PHYSICAL ACTIVITY AND NUTRITION, IN ADDITION TO ORAL HEALTH. A SUMMARY OF HOW THE HOSPITAL HAS BEEN ADDRESSING SOME OF THE NEEDS IDENTIFIED IN THE CHNA IS AS FOLLOWS:1. ALCOHOL AND OTHER DRUG ABUSE (AODA) -AODA MISUSE TEAM -DARJUNE RECOVERY COACHING -DRUG DROP BOXES IN CLINICS AND PHARMACIES -INFORMATION POWERPOINT TO DECREASE UNDERAGE DRINKING AND DRUGS -EXPLORE SOBER LIVING (IN PARTNERSHIP WITH DARJUNE)2. NUTRITION AND PHYSICAL ACTIVITIES -OCONTO COUNTY FARMERS MARKET -SAFETY FAIR -DONATE HEALTH PLATE - LOCAL FOOD PANTRY SUPPORT AND EDUCATION -PLANT A SEED - GROWING AN ADDITIONAL ROW OF VEGETABLES IN YOUR GARDENS TO DONATE TO FOOD PANTRIES -BELLIN HEART RUN/WALK 5K - MARINETTE, WI -SUMMER MEAL PROGRAM OCONTO HOSPITAL & MEDICAL CENTER, INC. PART V, SECTION B, LINE 13H: PRESUMPTIVE ELIGIBILITY INCLUDES FACTORS AS: HOMELESS, DECEASED WITH NO KNOWN ESTATE, APPROVED COURT BANKRUPTCY, PAYMENT ASSISTANCE RANK ORDER SCORE, ELIGIBLE FOR STATE OF WI FOOD SHARE PROGRAM. OCONTO HOSPITAL & MEDICAL CENTER, INC. PART V, SECTION B, LINE 16J: DISCLOSURE UNDER REVENUE PROCEDURE 2015-21:FAILURE TO PROVIDE REFUNDS OF OVERPAYMENTS TO FAP-ELIGIBLE INDIVIDUALS(1) DESCRIPTION OF THE FAILURE: (A) TYPE OF FAILURE: IN ORDER TO COMPLY WITH IRS SECTION 501(R) PATIENT FINANCIAL ASSISTANCE REQUIREMENTS, OCONTO HOSPITAL AND MEDICAL CENTER (OHMC) HAS INSTITUTED VARIOUS POLICIES AND PROCEDURES. IT HAS BEEN OHMC'S BELIEF THAT THESE POLICIES AND PROCEDURES WERE CONSISTENT WITH THE INTENT OF THE REGULATIONS PROVIDING FINANCIAL ASSISTANCE TO PATIENTS WHO WOULD FIND THE PATIENT RESPONSIBILITY OF THE BILL TO BE AN EXCESSIVE FINANCIAL BURDEN. THE POLICIES AND PROCEDURE WERE CREATED UNDER THE GUIDANCE OF INDUSTRY EXPERTS AND WERE REVIEWED AS PART OF AN IRS AUDIT IN JUNE 2017. OHMC HAS BEEN FOLLOWING THE POLICIES AND PROCEDURES SINCE EARLY 2016.OHMC'S INTERPRETATION OF THE REGULATIONS WAS TO APPLY THE FINANCIAL ASSISTANCE PROCESS TO FUTURE PATIENT FINANCIAL RESPONSIBILITY AND PATIENT BALANCES AT THE TIME OF A PATIENT'S ELIGIBILITY FOR FINANCIAL ASSISTANCE. ELIGIBILITY IS DETERMINED BY THE PATIENT COMPLETING AN APPLICATION FOR FINANCIAL ASSISTANCE, PRIOR ELIGIBILITY AND/OR PRESUMPTIVE ELIGIBILITY. (B) CAUSE OF THE FAILURE: THE GAP IN OHMC'S INTERPRETATION OF THE REGULATION STEMS FROM THE FAILURE TO CONSIDER PRIOR PATIENT PAYMENTS THAT COULD HAVE BEEN A PART OF THE PATIENT FINANCIAL ASSISTANCE PROGRAM. THIS GAP HAS EXISTED SINCE THE INCEPTION OF THE IRS SECTION 501(R) PATIENT FINANCIAL ASSISTANCE PROGRAM. (C) HOSPITAL FACILITY WHERE THE FAILURE OCCURRED: OCONTO HOSPITAL AND MEDICAL CENTER (D) DATE(S) OF THE FAILURE AND ITS DISCOVERY: THE FAILURE BEGAN ON OCTOBER 1, 2016, WHICH IS THE DATE THE 501(R) REGULATIONS BECAME EFFECTIVE FOR OHMC, AND CONTINUED UNTIL JUNE 30, 2019. SUCH FAILURE WAS DISCOVERED WITH THE ASSISTANCE OF LEGAL COUNSEL ON JULY 9, 2019, UPON REVIEW OF CERTAIN OF THE HOSPITAL'S POLICIES FOR COMPLIANCE WITH SECTION 501(R) OF THE INTERNAL REVENUE CODE OF 1986, AS AMENDED (THE "CODE"), AND THE REGULATIONS THEREUNDER. (E) NUMBER OF OCCURRENCES: OHMC AND ITS AFFILIATES INITIAL REVIEW OF ACCOUNTS DETERMINED APPROXIMATELY 2,400 INDIVIDUALS MAY HAVE BEEN IMPACTED BY THE FAILURE. THIS NUMBER WAS DERIVED AT BY REVIEWING ALL INDIVIDUALS THAT HAD MADE A PERSONAL PAYMENT FOR A DATE OF SERVICE AFTER 9/30/2016 WHO WERE AT ANY POINT APPROVED FOR ANY LEVEL OF CHARITY CARE AT OHMC AND ITS AFFILIATES (DERIVED AT BY ANY CHARITY CARE ADJUSTMENT ON ANY OF THAT INDIVIDUALS ENCOUNTERS FROM ANY DATE OF SERVICE AFTER 9/30/2016). THIS PROCESS GREW TO FINALLY EXAMINING 2,884 UNIQUE GUARANTORS (COUNTED IN THE UNIQUE NUMBER OF GUARANTOR ACCOUNTS, WHICH MAYBE HOLD MORE THAN ONE UNIQUE INDIVIDUALS IS CASES WHERE A MINOR IS ON THEIR GUARDIANS GUARANTOR ACCOUNT). THROUGH A PROCESS OF MANUALLY REVIEWING EACH GUARANTOR CHARITY CARE APPLICATION (SUMMARIZED WITH NOTES WITHIN EPIC), IT WAS DEEMED THAT 1,666 GUARANTOR ACCOUNTS WERE OWED A REFUND OF $513,069 IN PREVIOUS PAYMENTS AND $50,300 IN INTEREST FROM THOSE PREVIOUS PAYMENTS (CALCULATED AT A 6% ANNUAL INTEREST RATE COMPOUNDED FROM THE ENCOUNTER DISCHARGE DATE UNTIL AUGUST 15, 2019). EACH INDIVIDUAL AND THEIR ASSOCIATED ACCOUNTS WERE EVALUATED FOR APPROPRIATE APPLICATION TO IRS SECTION 501(R) PATIENT FINANCIAL ASSISTANCE PROGRAM GUIDELINES. THE QUANTITIES WERE SEPARATED AS FOLLOWS (NOTE, THE SUM OF GUARANTORS BEING GREATER THAN THE SUM AMOUNT IS DUE TO PATIENTS VISITING NUMEROUS CORPORATIONS): -OCONTO HOSPITAL AND MEDICAL CENTER = 265 GUARANTORS, $47,226 REFUNDS, $4,123 INTEREST (F) DOLLAR AMOUNTS INVOLVED: OHMC AND ITS AFFILIATES INITIAL REVIEW OF ACCOUNTS HAS DETERMINED THE MAXIMUM FINANCIAL IMPACT OF THE PROGRAM FAILURE IS $563,369, AS EXPLAINED IN SECTION 1.E INCLUDED $513,069 IS PATIENT PAYMENTS AND $50,300 IN INTEREST FROM THOSE PAYMENTS. EACH INDIVIDUAL AND THEIR ASSOCIATED ACCOUNTS WERE EVALUATED FOR APPROPRIATE APPLICATION TO IRS SECTION 501(R) PATIENT FINANCIAL ASSISTANCE PROGRAM GUIDELINES.(2) DESCRIPTION OF THE CORRECTION OF THE FAILURE: (A) METHOD AND DATE OF CORRECTION; DESCRIPTION OF HOW AFFECTED INDIVIDUALS WERE RESTORED TO THE POSITION THEY WOULD HAVE BEEN IN HAD THE FAILURE NOT OCCURRED: IN JULY OF 2019, OHMC REVISED ITS FINANCIAL ASSISTANCE POLICY (THE "FAP"). ADDITIONALLY, THE OHMC REVENUE CYCLE TEAM (THE INTERNAL GROUP RESPONSIBLE FOR THE APPLICATION OF THE FAP) HAS BEEN TRAINED ON THE APPROPRIATE APPLICATION OF THE FAP. IN JULY AND AUGUST OF 2019, OHMC AND ITS AFFILIATES USED ITS BEST EFFORTS TO PROVIDE EACH AFFECTED INDIVIDUAL WITH AN EXPLANATION OF THE ERROR, A CORRECTED BILLING STATEMENT, AND A REFUND OF ANY PAYMENTS THE INDIVIDUALS MADE IN EXCESS OF THE AMOUNTS OWED AFTER FAP DISCOUNTS ARE APPLIED (IN CASES IN WHICH THE EXCESS WAS $5 OR MORE). DURING THE PROCESS OF REFUNDING INDIVIDUALS, CHECKS WERE SENT TO ALL IDENTIFIED INDIVIDUALS AND APPROXIMATELY 63 WERE IDENTIFIED AS DECEASED. STEPS WERE TAKEN TO IDENTIFY THE INDIVIDUAL FINANCIALLY RESPONSIBLE OF THE DECEASED ESTATE. NO KNOWN ISSUED REFUND CHECKS OF BEEN RETURNED.(3) DESCRIPTION OF THE PRACTICES OR PROCEDURES THAT THE HOSPITAL REVISED OR NEWLY ESTABLISHED TO MINIMIZE THE LIKELIHOOD OF THE TYPE OF FAILURE RECURRING AND TO FACILITATE THE PROMPT IDENTIFICATION AND CORRECTION OF ANY SUCH FUTURE FAILURES THAT DO OCCUR: (A)WHILE OHMC IS COMFORTABLE THAT THE REVENUE CYCLE TEAM IS ACCURATELY AND APPROPRIATELY APPLYING THE IRS SECTION 501(R) PATIENT FINANCIAL ASSISTANCE PROGRAM REQUIREMENTS, A NUMBER OF PROCESSES HAVE BEEN PUT INTO PLACE TO ENSURE NO ADDITIONAL FAILURES OCCUR. THE PROCESSES INCLUDE: 1. IMPLEMENTATION OF A FINANCIAL ASSISTANCE DATABASE; 2. A MULTI-TIER SIGN-OFF PROCESS FOR NEW FINANCIAL ASSISTANCE PROGRAM PARTICIPANTS; 3. EXPLORE THE PRACTICALITY OF IMPLEMENTING THE EPIC FINANCIAL ASSISTANCE MODULE; 4. INTERNAL AUDITS (PERFORMED BY THE CORPORATE COMPLIANCE OFFICE) SCHEDULED IN SEPTEMBER 2019, DECEMBER 2019 AND ANNUALLY THEREAFTER. 6 1 - BELLIN HEALTH MARINETTE 2820 ROOSEVELT ROAD MARINETTE WI 54143 RURAL HEALTH CLINIC, AMBUL 2 - BELLIN HEALTH CRIVITZ 218 S US HWY 141 SUITE 100 CRIVITZ WI 54114 RURAL HEALTH CLINIC 3 - BELLIN HEALTH PESHTIGO 441 FRENCH STREET PESHTIGO WI 54162 RURAL HEALTH CLINIC 4 - BELLIN HEALTH MENOMINEE 1100 10TH STREET MENOMINEE MI 49858 RURAL HEALTH CLINIC 5 - BELLIN HEALTH LAKEWOOD 15481 COMMERCIAL RD STE E LAKEWOOD WI 54138 PRIMARY CARE CLINIC 6 - BELLIN HEALTH DAGGETT 106 S SCHOOL ROAD DAGGETT MI 49821 RURAL HEALTH CLINIC PART I, LINE 6A: OCONTO HOSPITAL AND MEDICAL CENTER IS INCLUDED IN THE BELLIN HEALTH SYSTEMS, INC. COMMUNITY BENEFIT REPORT. PART I, LINE 7: AMOUNTS ARE CALCULATED BASED ON THE COST TO CHARGE RATIOS AND WORKSHEET 2 PROVIDED BY THE IRS. PART I, LN 7 COL(F): BAD DEBT EXPENSE OF $1,926,711 INCLUDED ON FORM 990, PART IX, LINE 25 WAS EXCLUDED FROM THE DENOMINATOR PER INSTRUCTIONS WHEN CALCULATING THE PERCENT TOTAL EXPENSES ON SCHEDULE H. PART II, COMMUNITY BUILDING ACTIVITIES: COORDINATION AND SUPPORT OF LOCAL EMS - COMMUNITY DISASTER DRILL, MASS CASUALTY DRILL, EDUCATION, SMOKE INHALATION KITS STOCKED AT THE HOSPITAL. WORK IN PARTNERSHIP WITH COUNTY HEALTH DEPARTMENTS TO MEET COMMUNITY NEEDS. PART III, LINE 2: THE BAD DEBT EXPENSE AT COST IS CALCULATED BASED ON THE COST TO CHANGE RATIOS. PART III, LINE 4: THE ATTACHED FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC BAD DEBT EXPENSE FOOTNOTE. HOWEVER, THE SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES DESCRIBES THE HOSPITAL'S POLICY ON PAGE 16 OF THE FINANCIAL STATEMENTS. CONSISTENT WITH BELLIN HEALTH SYSTEMS' MISSION, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. THEREFORE, BELLIN HEALTH SYSTEMS HAS DETERMINED IT HAS PROVIDED IMPLICIT PRICE CONCESSIONS TO UNINSURED PATIENTS AND PATIENTS WITH OTHER UNINSURED BALANCES (FOR EXAMPLE, COPAYS AND DEDUCTIBLES). THE IMPLICIT PRICE CONCESSIONS INCLUDED IN ESTIMATING THE TRANSACTION PRICE REPRESENT THE DIFFERENCE BETWEEN AMOUNTS BILLED TO PATIENTS AND THE AMOUNTS BELLIN HEALTH SYSTEMS EXPECTS TO COLLECT BASED ON ITS COLLECTION HISTORY WITH THOSE PATIENTS. BELLIN HEALTH SYSTEMS' POLICY IS TO PROVIDE A 35% DISCOUNT FROM ESTABLISHED CHARGES TO UNINSURED PATIENTS. THIS POLICY DID NOT CHANGE IN 2019 AND 2018. PART III, LINE 8: THE AMOUNTS REPORTED FOR MEDICARE WERE CALCULATED USING A COST TO CHARGE RATIO. THE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT FOR THE FOLLOWING REASONS. IRS REV RUL 69-545 WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENT HEALTH BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. IN ADDITION, ELDERLY PATIENTS ARE OFTEN UNDERSERVED AND EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT EXEMPT HOSPITALS, CMS WOULD NEED TO PROVIDE THESE SERVICES. PART III, LINE 9B: FOR PATIENTS WHO CANNOT MEET THE EXPECTATIONS OF THE DEBT COLLECTION POLICY, THE ORGANIZATION OFFERS FINANCIAL ASSITANCE. THE ORGANIZATION WILL NOT ENGAGE IN EXTRAORDINARY COLLECTION ACTIONS BEFORE DETERMING WHETHER A GUARANTOR IS ELIGILBE FOR ASSISTANCE UNTER THE FINANCIAL ASSISTANCE POLICY. ALL PATIENTS ARE OFFERED A PLAIN LANGUAGE SUMMARY EXPLAINING THE FINANCIAL ASSISTANCE PROGRAM AS PART OF THE REGISTRATION PROCESS IN ADDITION, ALL STATEMENTS INCLUDE INFORMATION REGARDING FINANCIAL ASSISTANCE AVAILABILITY. PART VI, LINE 2: THE ORGANIZATION HAS A KEY STRATEGIC OBJECTIVES OF "THE BEST CARE & HEALTHIEST COMMUNITIES" FOCUSED ON INCREASING YEARS OF QUALITY LIFE BY PROVIDING APPROPRIATE, HIGHEST QUALITY, SAFE AND COORDINATED CARE THAT IS AFFORDABLE FOR EVERYONE. WITH A RELENTLESS DESIRE TO IMPROVE HEALTH AND WELL-BEING, WE USE OUR EXPERTISE, TECHNOLOGY, RELATIONSHIPS, FINANCIAL AND OTHER RESOURCES TO ADDRESS THE SOCIAL DETERMINANTS OF HEALTH AND POSITIVELY IMPACT THE HEALTH AND WELL-BEING OF OUR COMMUNITIES. WE ANNUALLY REVIEW THE COUNTY HEALTH RANKINGS THROUGH THE UW POPULATIONS HEALTH DEPARTMENT, MINE OUR PATIENT DATA BY REGION FOR THE HEALTH AREAS MOST IN NEED OF IMPROVEMENT AND MANAGE THIS THROUGH OUR PRIMARY CARE PROVIDER RELATIONSHIPS WITH KEY QUALITY INDICATORS. PART VI, LINE 3: INFORMATION ON GOVERNMENT ASSISTANCE PROGRAMS AND THE CHARITY CARE PROGRAM IS MADE AVAILABLE TO PATIENTS IN THE EMERGENCY ROOM AND AT THE TIME OF REGISTRATION. ADDITIONALLY, THE INFORMATION IS INCLUDED IN PATIENT STATEMENTS AND LETTERS FROM THE BILLING OFFICE. PART VI, LINE 4: THE ORGANIZATION IS LOCATED IN THE CITY OF OCONTO, WISCONSIN. ITS PRIMARY SERVICE AREA IS THE CITY OF OCONTO AND ITS SECONDARY SERVICE AREA SPREADS TO THE NORTHERN PORTION OF OCONTO COUNTY AND SOUTHERN MARINETTE COUNTY. THE CITY OF OCONTO HAS A POPULATION OF 4,500. 17% OF THE POPULATION IS OVER AGE 65 AND 8.8% OF THE POPULATION IS BELOW THE POVERTY LINE. PART VI, LINE 5: THE ORGANIZATION IS A STEERING TEAM MEMBER OF THE HEALTHY OCONTO COUNTY IMPROVEMENT WORK ALONG WITH HSHS ST. CLARE HOSPITAL AND OCONTO COUNTY PUBLIC HEALTH. THE ORGANIZATION ACTIVELY PARTICIPATES IN THE OCONTO AREA CHAMBER OF COMMERCE BUSINESS EXPOR, COPPERFEST SPONSORSHIP, NEWCAP AND HUMANE SOCIETY FOOD DRIVES. IN ADDITION THE ORGANIZATION IS A SOLE COMMUNITY HOSPITAL WITH AN EMERGENCY ROOM AVAILABLE 24/7 TO ALL. PART VI, LINE 6: THE ORGANIZATION, IN PARTNERSHIP WITH BELLIN HEALTH SYSTEMS, INC., CONTINUES TO SERVE IT'S COMMUNITY. X X X X 0 0 0 0 0 0 0 0 0 GEORGE KERWIN - TERMED BOARD MEMBER 0 597016 0 430400 0 55149 0 19788 0 18689 0 1121042 0 0 LAURA HIEB BOARD MEMBER 0 240115 0 60000 0 25528 0 0 0 2795 0 328438 0 0 LAURA CORMIER CEO 147277 0 10000 0 2286 0 6613 0 20810 0 186986 0 0 0 JAMES DIETSCHE BOARD MEMBER 0 383423 0 110000 0 414 0 3735 0 21812 0 519384 0 0 CHARLES HEYKA MD PRESIDENT OF MEDICAL STAFF 381098 0 0 0 1188 0 11624 0 21530 0 415440 0 0 0 PAWNEET SING MD PHYSICIAN 440919 0 136362 0 162 0 8330 0 1760 0 587533 0 0 0 CALVIN NOGLER MD PHYSICIAN 177148 0 122174 0 1188 0 8214 0 18523 0 327247 0 0 0 MICHAEL BRENNER MD PHYSICIAN 336572 0 0 0 162 0 130 0 19674 0 356538 0 0 0 JAMES OPOIEN MD PHYSICIAN 196057 0 90099 0 2286 0 5103 0 18566 0 312111 0 0 0 JON SIMMONS MD PHYSICIAN 145374 0 171771 0 414 0 5702 0 8829 0 332090 0 0 0 A WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 2011-08-18 14000000 FACILITY AND SERVICE EXPANSION 0 0 0 A 466667 14000000 36149 132033 13831818 2012 0 0 1 1 A 0 0 0 0 0 0 1 A 0 1 0 0 0 0 0 0 A 1 FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS TWO MEMBERS, BELLIN MEMORIAL HOSPITAL, INC. AND OCONTO MEMORIAL HOSPITAL CITIZENS FOUNDATION, INC. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERS OF THE ORGANIZATION HAVE THE POWER TO APPOINT/ELECT THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B THE MEMBERS ALSO HAVE THE POWER TO APPROVE, BUT NOT LIMITED TO, THE PHILOSOPHY, MISSION, AND VALUE OF THE ORGANIZATION, STRATEGIC PLANS, THE ANNUAL OPERATING AND CAPITAL BUDGET, AMENDMENTS OR RESTATEMENTS OF THE ARTICLES OF INCORPORATION AND BYLAWS. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS REVIEWED IN DETAIL BY SENIOR ADMINISTRATION AND IS PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION REQUESTS AN ANNUAL UPDATE FROM ALL BOARD MEMBERS WHO SIGN THE POLICY. ALL DOCUMENTS ARE PROVIDED BACK TO ADMINISTRATION AND REVIEWED. IF THERE IS A CONFLICT OF INTERST, THE CORPORATE COMPLIANCE OFFICER IS NOTIFIED. MEMBERS OF THE BOARD WHO HAVE A CONFLICT OF INTEREST WITH A BOARD DECISION ABSTAIN FROM VOTING ON THE ISSUE. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION OF KEY EXECUTIVES ARE SET BY THE EXECUTIVE COMMITTEE OF THE BOARD WITHOUT CONFLICT OF INTEREST AND IS SUPPORTED BY MARKET DATA FROM SURVEYS AND AN INDEPENDENT CONSULTANT'S REPORT. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION CONSIDERS THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS PROPERTY OF THE ORGANIZATION AND THEREFORE ARE NOT AVAILABLE TO THE PUBLIC. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN OCONTO MEMORIAL HOSPITAL CITIZENS' FOUNDATION, INC. 45,677. FORM 990, PART XI, LINE 2B-2C THE ORGANIZATION IS INCLUDED IN THE CONSOLIDATED AUDIT OF BELLIN HEALTH SYSTEMS, INC. THE BOARD OF DIRECTORS OF BELLIN HEALTH SYSTEMS, INC. ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND SELECTION OF AN INDEPENDENT AUDITOR. 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