2020-09-04T11:42:15-05:00 2019-12-31 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2019-01-01 390944012 MOUNDVIEW MEMORIAL HOSPITAL & CLINICS MOUN 6083393331 402 WEST LAKE STREET FRIENDSHIP WI 53934 FRANK PEREZ-GUERRA CEO 6083393331 2020-09-02 1 MICHAEL J PETERSON CPA P01833529 2187224705 2020-09-02 216.54.158.12 2020-09-02 15:35:16 CD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 9747BB8E0DC0E78824B7C9EDF76D609BB7F00C05 2019 2021-01-29 14:40:06Z GUNDERSEN MOUNDVIEW HOSPITAL AND CLINICS FRANK PEREZ-GUERRA 402 WEST LAKE STREET FRIENDSHIP WI 53934 18807259 0 X HTTP://WWW.GUNDERSENHEALTH.ORG/MOUNDVIEW/ X 1959 WI WE WILL ENHANCE THE HEALTH AND WELL-BEING OF OUR COMMUNITIES WHILE ENRICHING EVERY LIFE WE TOUCH, INCLUDING PATIENTS, FAMILIES AND STAFF. 8 3 166 60 0 0 179418 104548 18037066 18470787 50264 76067 28028 140327 18294776 18791729 0 1250 0 0 9686974 8952679 0 0 0 9110087 9318108 18797061 18272037 -502285 519692 14211453 12862094 5541149 3650365 8670304 9211729 WE WILL DISTINGUISH OURSELVES THROUGH EXCELLENCE IN PATIENT CARE, EDUCATION, AND IMPROVED HEALTH IN THE COMMUNITIES WE SERVE. 0 0 15007847 1250 18493153 THE HOSPITAL IS A GENERAL MEDICAL CRITICAL ACCESS HOSPITAL LICENSED FOR 25 BEDS. DURING FISCAL YEAR 2019, THE HOSPITAL HAD 440 ACUTE INPATIENT DAYS AND 280 MEDICARE SKILL NURSING DAYS (SWING BED). THE HOSPITAL ALSO HAD 6,129 EMERGENCY ROOM / URGENT CARE VISITS. 15007847 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 212 0 166 1 0 0 0 0 0 0 0 0 0 0 0 0 X 8 3 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 0 0 WI X FRANK PEREZ-GUERRA 6083393331 402 WEST LAKE STREET FRIENDSHIP WI 53934 BARBARA ALBRECHT BOARD MEMBER (THRU DECEMBER) 2.50 X 0 0 0 MICHAEL CUMMINGS BOARD MEMBER 2.50 X 0 0 0 BRYAN ERDMANN BOARD MEMBER 2.50 X 0 267981 64725 MICHAEL O'NEILL BOARD MEMBER (THRU DECEMBER) 2.50 X 0 183236 47528 ROXANNE POTTS BOARD MEMBER 2.50 X 0 124384 35652 KRAIG SCHUSTER BOARD MEMBER 2.50 X 0 0 0 RICHARD STERNHAGEN CHAIR 2.50 X X 0 0 0 PAUL FISCH VICE-CHAIR 2.50 X X 0 108816 37498 SARAH ROSSMAN SECRETARY 2.50 X X 0 120590 22454 RENEE SCHINDLBECK TREASURER 2.50 X X 0 0 0 FRANK PEREZ GUERRA CEO 40.00 1.00 X 0 171861 13054 SHERYL OBERNBERGER NURSE PRACTITIONER 40.00 X 167651 0 37396 DIANA BRONIEC DIRECTOR 40.00 X 141670 0 7430 BRONWYN DILLEY NURSE PRACTITIONER 40.00 X 145388 0 28066 LINDA CHARLES NURSE PRACTITIONER 40.00 X 128469 0 18900 JUDY NOWICKI DIRECTOR 40.00 X 116257 0 17623 699435 976868 330326 9 0 1 0 EMCARE PHYSICIAN SERVICES INC 7032 COLLECTION CENTER DRIVE CHICAGO IL 60693 ER PHYSICIAN COVERAGE 2122041 GUNDERSEN HEALTH SYSTEM 1900 SOUTH AVENUE LA CROSSE WI 54601 ADMINISTRATIVE AND CLINICAL SERVICES 1495821 TOTALMED STAFFING INC 221 W COLLEGE AVE - FLOOR 2 APPLETON WI 549115759 CONTRACT NURSING SERVICES 283596 FIRST REFLECTIONS INC 228 N PINE STREET ADAMS WI 53910 CRNA SERVICES 217878 SHARED IMAGING SERVICES PO BOX 88450 MILWAUKEE WI 532880450 NUCLEAR MEDICINE/EKG TESTING SERVICES 145022 17 75766 15360 13422 104548 NET PATIENT SERVICE REVENUE 621300 18390267 18390267 MEDICAL BUILDING RENT 531120 68772 68772 11748 11748 18470787 72303 72303 23764 15530 8234 8234 8234 3764 0 3764 3764 3764 E.H.R INCENTIVE 900099 22366 22366 109727 109727 132093 18791729 18493153 0 194028 X 1250 1250 184915 184915 6913248 5647276 1265972 133875 108861 25014 1203228 910730 292498 517413 413602 103811 31323 31323 49300 49300 4832752 4156563 676189 66642 850 65792 523107 397410 125697 651 651 304218 269355 34863 36095 25555 10540 45850 29375 16475 153633 137755 15878 749259 662336 86923 50059 50059 BAD DEBT EXPENSE 1072009 1072009 MEDICAL SUPPLIES 911094 910596 498 REPAIRS & MAINTENANCE 281796 238875 42921 COLLECTION EXPENSE 118550 118550 91770 24798 66972 18272037 15007847 3264190 0 700 700 2699910 2954609 3016239 2237422 279249 241475 52744 214447 7488616 1403285 6362175 6085331 1800436 1128110 14211453 12862094 2545124 1749773 25250 3090 2099561 871214 1866561 0 30941 5541149 3650365 X 8139868 8659560 530436 552169 8670304 9211729 14211453 12862094 X 519692 21733 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1492 1492 0 PART II-B, LINE 1: MOUNDVIEW MEMORIAL HOSPITAL & CLINICS 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. THE WHA HAS NOTIFIED MOUNDVIEW MEMORIAL HOSPITAL & CLINICS THAT $1,492 OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. 76500 76500 5145928 515291 4630637 1822239 629837 1192402 443949 258157 185792 6085331 RIGHT-OF-USE ASSETS - OPERATING LEASES 30941 RECEIVABLE FROM THIRD PARTY PAYORS 545000 RECEIVABLE FROM POLIVKA TRUST 552169 1128110 OPERATING LEASE LIABILITIES 30941 30941 1 1 X 1 X 1 X 1 1 1 0 1 1 53374 53374 0.00290 2828895 1695414 1133481 0.06200 2882269 1695414 1186855 0.06490 186327 15420 170907 0.00940 13845 13845 0.00080 6746278 3310324 3435954 0.18800 6946450 3325744 3620706 0.19820 9828719 5021158 4807561 0.26310 1 460964 36877 6926938 6966844 -39906 X 1 1 1 1 MOUNDVIEW MEMORIAL HOSPITAL 402 WEST LAKE STREET FRIENDSHIP WI 53934 HTTPS://WWW.GUNDERSENHEALTH.ORG/MOUNDV 1014 X X X X MOUNDVIEW MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 18 1 0 1 1 X SEE SUPPLEMENTAL INFO X 1 18 1 SEE SUPPLEMENTAL INFO 0 1 X 200.000000000000 400.000000000000 X X X X 1 1 X X X X 1 X SEE SUPPLEMENTAL INFORMATION X SEE SUPPLEMENTAL INFORMATION X SEE SUPPLEMENTAL INFORMATION 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: THE HOSPITAL COLLABORATED WITH THE ADAMS COUNTY PUBLIC HEALTH, UW EXTENSION, ADAMS COUNTY GOVERNMENT, ADAMS-FRIENDSHIP SCHOOL DISTRICT AND COMMUNITY MEMBERS TO CREATE AND CONDUCT A HEALTH SURVEY OF THE GENERAL PUBLIC IN MARCH 2016. THERE WERE 602 RESPONDENTS, MAKING IT A STATISTICALLY SIGNIFICANT SAMPLE OF THE COUNTY. THE SURVEY WAS WIDELY DISTRIBUTED VIA A SURVEY LINK SHARED THROUGH ORGANIZATION EMAIL LISTS, ORGANIZATION FACEBOOK PAGES, AREA NEWSLETTERS, NEWSPAPER AND RADIO. INDIVIDUALS WERE LIMITED TO ONE SURVEY PER EMAIL ADDRESS. PAPER SURVEYS WERE DISTRIBUTED THROUGH FOOD PANTRIES, LIBRARY, MEALS ON WHEELS, SENIOR MEAL SITES AND THE LIGHTED SCHOOL HOUSE PROGRAM TO OBTAIN INPUT FROM THOSE WITHOUT COMPUTERS AND OTHER DIFFICULT TO REACH POPULATIONS. SURVEY RESPONDENTS WERE ASKED TO RANK ISSUES THAT MAY IMPACT THEIR COMMUNITY'S HEALTH ON A SEVEN POINT SCALE AND TO NAME THEIR TOP TWO HEALTH CONCERNS. A SIMILAR SURVEY WAS DISTRIBUTED VIA EMAIL TO 43 COMMUNITY STAKEHOLDERS WHO WERE IDENTIFIED AS HAVING A BROAD, VESTED INTEREST IN THE COMMUNITY. THESE INCLUDED MEDICAL PROVIDERS AND PROFESSIONALS, SERVICE AGENCIES (INCLUDING THOSE REPRESENTING LOW INCOME AND DISABILITY POPULATIONS), SCHOOL LEADERS, COUNTY GOVERNMENT, BUSINESS LEADERS AND OTHER OFFICIALS. COMMUNITY STAKEHOLDER AND PATIENT ADVISORY COUNCIL FOCUS GROUPS WERE HELD IN 2018 TO REVIEW AND PRIORITIZE SEVEN IDENTIFIED NEEDS. MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: WHILE THE NEEDS ASSESSMENT IS SPECIFIC TO GUNDERSEN MOUNDVIEW, THE HOSPITAL COLLABORATED WITH OTHER ORGANIZATIONS IN OBTAINING AND ANALYZING DATA INCLUDING ADAMS COUNTY HEALTH PUBLIC HEALTH AND THE BE HEALTHY ADAMS COUNTY COALITION WHICH INCLUDED REPRESENTATIVES FROM ADAMS COUNTY HEALTH AND HUMAN SERVICES, ADAMS COUNTY UW EXTENSION, ADAMS COUNTY GOVERNMENT, ADAMS-FRIENDSHIP SCHOOL DISTRIC AND COMMUNITY MEMBERS AT LARGE. MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: GUNDERSEN MOUNDVIEW CONTINUES TO ADDRESS IDENTIFIED HEALTH NEEDS THROUGH OUR IMPLEMENTATION PLAN. "CHRONIC DISEASE AND CONDITIONS" ARE ADDRESSED BY OUR PARTICIPATION IN VARIOUS COALITIONS AND EVENTS. SOME EXAMPLES INCLUDE: BE HEALTHY ADAMS COUNTY COALITIONS - WHICH ESTABLISHES INITIATIVES TO INCREASE AND IMPROVE PHYSICAL ACTIVITY AND NUTRITION, SPONSORSHIP OF AREA FARM MARKETS TO IMPROVE ACCESS TO FRUITS/VEGETABLES, PARTICIPATING ON THE YMCA STEERING COMMITTEE WHICH IS WORKING ON THE ESTABLISHMENT OF A SATELLITE YMCA IN OUR COUNTY, ADAMS COUNTY CANCER AWARENESS TEAM PROMOTING AWARENESS OF CANCER AND RELATED SCREENINGS, AND SPONSORSHIP/PARTICIPATION IN ADAMS COUNTY SUICIDE AWARENESS COALITION. WE HAVE INCREASED OUR NUMBER OF MENTORS IN THE ELEMENTARY SCHOOL BY 45% (FROM 20 TO 29 MENTORS) OVER THE PRIOR YEAR. MENTORS HELP BUILD YOUTH RESILIENCY BY MITIGATING THE IMPACT OF ADVERSE CHILDHOOD EXPERIENCES. WE IMPLEMENTED SAFE SITTER AND HOME ALONE CLASSES TO ASSIST FAMILIES WHOSE CHILDREN ARE HOME ALONE WHILE PARENTS ARE WORKING. WE ARE IN THE PLANNING STAGES OF IMPLEMENTING A GRIEF SUPPORT GROUP - A NEED THAT WAS IDENTIFIED THROUGH COLLABORATIVE WORK WITH THE AGING DEPARTMENT. WE CONTINUE TO ADDRESS "SUBSTANCE ABUSE" THROUGH OUR SUPPORT/COLLABORATION WITH FAMILY HEALTH LA CLINICA ROCHE-A-CRI BEHAVIORAL HEALTH AND RECOVERY CENTER WHICH INCLUDES SERVING ON THEIR COMMITTEE. WE CONTINUE TO SERVE ON THE DRUG FREE COALITION AND PROMOTE DRUG TAKE BACK EVENTS. WE PROVIDE LAB SUPPORT (OVER 542 DRUG COLLECTIONS IN 2019 ALONE) TO THE COUNTY DRUG TREATMENT COURT. HEALTH CARE COST AND ACCESS" IS CONTINUALLY ADDRESSED. SEVERAL NEW SPECIALTY PROVIDERS WERE ADDED IN 2019 AND ARE NOW SEEING PATIENTS LOCALLY. WE RECRUITED A NEW NURSE PRACTITIONER TO PRIMARY CARE. THERE REMAINS A NEED TO CONTINUE RECRUITMENT IN BOTH AREAS. THROUGH SHARED RESOURCES VIA OUR AFFILIATION WITH GUNDERSEN, WE CONTINUE TO SEE COST SAVINGS THROUGHOUT OUR ORGANIZATION. WORKFORCE DEVELOPMENT" HAS BEEN ADDRESSED BY PARTICIPATING ON THE COUNTY ECONOMIC DEVELOPMENT COUNCIL, CHAMBER OF COMMERCE BOARD AND THE NEW UNIVERCITY ALLIANCE COALITION. WE PROVIDED CLINICAL ROTATIONS/INTERNSHIP OPPORTUNITIES TO 15 STUDENTS IN 2019. WE CONTINUE TO PROVIDE EDUCATION AND TUITION REIMBURSEMENT PROGRAMS FOR OUR STAFF. 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, LINE 16A, 16B, 16C PART V, LINE 16A, FAP WEBSITE:HTTPS://WWW.GUNDERSENHEALTH.ORG/APP/FILES/PUBLIC/8939/FINANCIAL-ASSISTANCE-MOUNDVIEW-FAP-FINANCIAL-ASSISTANCE-POLICY.PDFPART V, LINE 16B, FAP APPLICATION WEBSITE:HTTPS://WWW.GUNDERSENHEALTH.ORG/APP/FILES/PUBLIC/8946/FINANCIAL-ASSISTANCE-ALL-LOCATIONS-FINANCIAL-ASSISTANCE-APPLICATION-ENGLISH.PDFPART V, LINE 16C, FAP PLAIN LANGUAGE SUMMARY WEBSITE:HTTPS://WWW.GUNDERSENHEALTH.ORG/APP/FILES/PUBLIC/8936/FINANCIAL-ASSISTANCE-MOUNDVIEW-PLAIN-LANGUAGE-SUMMARY.PDF 2 1 - GUNDERSEN FRIENDSHIP CLINIC 402 WEST LAKE STREET FRIENDSHIP WI 53934 RURAL HEALTH CLINIC 2 - GUNDERSEN WESTFIELD CLINIC 207 NORTH PIONEER PARK ROAD WESTFIELD WI 53964 RURAL HEALTH CLINIC 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. 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 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 UNCOLLECTIBLE ACCOUNTS. PART III, LINE 8: 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. THE COST METHODOLOGY USED TO DETERMINE MEDICARE ALLOWABLE COSTS IS A STEP-DOWN ALLOCATION OF COSTS FROM NON-REVENUE AREAS TO REVENUE AREAS. THIS ALLOCATION IS DONE FOLLOWING MEDICARE RULES AND REGULATIONS. 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 COLLECTS, REVIEWS AND ANALYZES LOCAL, REGIONAL AND STATE DATA SOURCES IN CONJUNCTION WITH THE LOCAL PUBLIC HEALTH DEPARTMENT TO ASSESS SPECIFIC UNMET COMMUNITY NEEDS. THIS DATA INCLUDES SURVEYS OF THE GENERAL COMMUNITY AS WELL AS COMMUNITY STAKEHOLDERS WITH A BROAD, VESTED INTEREST IN THE COMMUNITY. IT ALSO INCLUDES TWO FOCUS GROUP SESSIONS OF COMMUNITY STAKEHOLDERS AND THE HOSPITAL'S PATIENT ADVISORY COUNCIL TO REVIEW AND HELP PRIORITIZE HEALTH NEEDS. THE HOSPITAL ANNUALLY REVIEWS THE COUNTY HEALTH RANKINGS AS WELL AS INFECTION CONTROL/COMMUNICABLE DISEASE REPORTS WITH THE PUBLIC HEALTH OFFICE. 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. IE MEDICAID, BADGER CARE. PART VI, LINE 4: THE ORGANIZATION SERVES ALL OF ADAMS COUNTY WISCONSIN (POPULATION APPROXIMATELY 19,973). ITS PRIMARY SERVICE AREA IS WITHIN THE CENTER OF THE COUNTY, BORDERED BY HWY 82 SOUTH, COUNTY C NORTH. THE COUNTY'S POVERTY RATE IS 13.9% HIGHER THAN THE STATE AVERAGE. OVER 70% OF STUDENTS ENROLLED IN THE SCHOOL DISTRICT ARE ELIGIBLE FOR FREE LUNCH. THE PERCENTAGE OF THOSE AGED 65 YEARS AND OVER IS 28% IS SIGNIFICANTLY HIGHER THAN THE STATE AND IS PROJECTED TO STEADILY INCREASE TO GREATER THAN 35% BY 2040. THERE IS A LOWER LEVEL OF COLLEGE EDUCATED RESIDENTS THAN STATE AVERAGES. PART VI, LINE 5: THE HOSPITAL WORKS WITH LOCAL PUBLIC HEALTH AND COMMUNITY SERVICE ORGANIZATIONS TO COORDINATE AND/OR PROVIDE SPONSORSHIP FUNDS TO SUPPORT COMMUNITY HEALTH PROGRAMS TO MEET THE NEEDS OF THE LOCAL COMMUNITY. THE HOSPITAL PROVIDES INKIND SUPPORT INCLUDING THE USE OF OUR MEETING ROOMS BY NONPROFIT GROUPS, DONATION OF EQUIPMENT/FURNITURE TO HABITAT FOR HUMANITY AND STAFF WHO SERVE ON NUMEROUS COMMUNITY COALITIONS AND HEALTH BOARDS. THE HOSPITAL BOARD INCLUDES COMMUNITY MEMBERS WHO ARE UNPAID. THE HOSPITAL ALSO PROVIDES SPONSORSHIPS OF EVENTS/PROGRAMS THAT HAVE HEALTH/WELLNESS EDUCATION BUILT INTO THEM. 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 BRYAN ERDMANN BOARD MEMBER 0 265097 0 500 0 2384 0 39331 0 25394 0 332706 0 0 MICHAEL O'NEILL BOARD MEMBER (THRU DECEMBER) 0 180943 0 500 0 1793 0 26732 0 20796 0 230764 0 0 ROXANNE POTTS BOARD MEMBER 0 119311 0 0 0 5073 0 15891 0 19761 0 160036 0 0 FRANK PEREZ GUERRA CEO 0 168946 0 500 0 2415 0 7000 0 6054 0 184915 0 0 SHERYL OBERNBERGER NURSE PRACTITIONER 137840 0 28779 0 1032 0 5274 0 32122 0 205047 0 0 0 BRONWYN DILLEY NURSE PRACTITIONER 127795 0 8072 0 9521 0 4130 0 23936 0 173454 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 ANY PERSON OVER THE AGE OF EIGHTEEN YEARS WHO IS A RESIDENT OF ADAMS COUNTY MAY BE A MEMBER OF THE CORPORATION. MEMBERSHIP MAY BE ATTAINED BY ANY SUCH PERSON WHO SHALL AGREE IN WRITING TO BECOME A MEMBER OF THIS CORPORATION BY SUBSCRIBING TO A MEMBERSHIP LIST OF SAID CORPORATION. ANNUAL MEMBERSHIPS WILL BE IN EFFECT FROM JULY 1ST TO JUNE 30TH OF EACH FISCAL YEAR. FORM 990, PART VI, SECTION A, LINE 7A EACH PERSON WHO WAS A MEMBER IN GOOD STANDING AS OF THE PREVIOUS JUNE 30TH IS ENTITLED TO ONE VOTE FOR EACH SEAT OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B MEMBERS OF THE ORGANIZATION MUST APPROVE BYLAW CHANGES. FORM 990, PART VI, SECTION B, LINE 11B THE 990 IS REVIEWED BY THE CEO PRIOR TO FILING. 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 CEO COMPENSATION IS BASED ON DIRECT NEGOTIATIONS BETWEEN THE BOARD MEMBERS WITHOUT CONFLICT AND THE INDIVIDUAL UTILIZING CURRENT RELEVANT MARKET SURVEYS AS A GUIDE WITH THE LANGUAGE OF CONTRACT GIVEN TO MMHC ATTORNEYS FOR REVIEW AND COMMENTS. SUBSEQUENT MODIFICATIONS ARE PERFORMANCE BASED AND MARKET DRIVEN. FOR OTHER OFFICERS AND KEY EMPLOYEES, THE CEO DETERMINES SALARY BASED ON THE MARKET, EXPERIENCE AND INDUSTRY SURVEY GUIDES. 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 IX, LINE 11G EMERGENCY ROOM SERVICE FEES: PROGRAM SERVICE EXPENSES 1,874,940. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,874,940. ANESTHESIA SERVICE FEES: PROGRAM SERVICE EXPENSES 224,278. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 224,278. LABORATORY SERVICE FEES: PROGRAM SERVICE EXPENSES 331,333. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 331,333. PHARMACY SERVICE FEES: PROGRAM SERVICE EXPENSES 49,557. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 49,557. FAMILY MEDICINE SERVICE FEES: PROGRAM SERVICE EXPENSES 609,823. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 609,823. OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 1,066,632. MANAGEMENT AND GENERAL EXPENSES 676,189. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,742,821. FORM 990, PART XI, LINE 9: CHANGE IN ASSETS HELD IN POLIVKA TRUST 21,733. 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