2019-11-14T08:03:06-06:00 2018-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2018-01-01 363314159 REGIONAL WEST PHYSICIANS CLINIC REGI 3086302877 4021 AVENUE B SCOTTSBLUFF NE 69361 MICHAEL ICKOWSKI CFO 3086302877 2019-11-13 1 WENDY R COOLEY P01523804 4023302660 209.34.201.180 2019-11-13 15:48:56 CS P 33304EFAA66B0CAA4E31B16BDD4AAC48293A938A B319C935D5CD5DD24452FA9CD51ABCBD1A9C8C2C 2018 2020-03-31 21:24:44Z MICHAEL ICKOWSKI 4021 AVENUE B SCOTTSBLUFF NE 69361 75136897 0 X WWW.RWHS.ORG X 1984 NE PROVIDE HEALTH CARE TO THE REGION INCLUDING THE UNDERSERVED. 13 0 413 20 17764 -27735 23359200 32693950 44101030 42387061 966 640 115734 17764 67576930 75099415 28392 29928 0 0 44014606 49638421 0 0 0 24140161 24718668 68183159 74387017 -606229 712398 4615240 8696596 5177129 8546087 -561889 150509 PROVIDE HEALTH CARE TO THE REGION INCLUDING THE UNDERSERVED. 0 0 67031075 29928 42387061 REGIONAL WEST PHYSICIANS CLINIC IS A MULTI-SPECIALTY MEDICAL GROUP OF MORE THAN 70 PHYSICIANS AND ASSOCIATED HEALTH CARE PROVIDERS. THE CLINIC IS A PHYSICIAN-LED, PHYSICIAN-GOVERNED SUBSIDIARY OF REGIONAL WEST HEALTH SERVICES. IN THE TRADITION OF THE MAYO CLINIC AND OTHER SUCCESSFUL EXAMPLES OF PHYSICIAN HOSPITAL INTEGRATION, REGIONAL WEST PHYSICIANS CLINIC IS COMMITTED TO PROVIDING THE HIGHEST QUALITY PATIENT CARE AND SERVICE, PATIENT-DRIVEN HEALTH CARE GOVERNANCE AND LEADERSHIP, AND COMMUNITY OUTREACH TO THE REGION. 67031075 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 1 62 0 1 413 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 13 0 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X MICHAEL ICKOWSKI 3086301111 4021 AVENUE B SCOTTSBLUFF NE 69361 VINCENT BJORLING MD CHAIR 40.00 2.00 X X 573621 0 46482 DAVID HOLDT MD PRESIDENT 40.00 3.00 X X 590706 0 47272 JOHN MENTGEN CEO 1.00 45.00 X X 0 519155 116443 MICHAEL ICKOWSKI TREASURER/CFO 1.00 45.00 X X 0 329384 76104 SEROZAN AMROLIWALLA MD DIRECTOR 40.00 X 266193 0 25645 BRENT ELLISON MD DIRECTOR 40.00 X 474756 0 56291 MARK HARTMAN MD DIRECTOR 40.00 1.00 X 651926 0 50331 JEFFREY HOLLOWAY MD DIRECTOR 40.00 2.00 X 714410 0 56665 KENT LACEY MD DIRECTOR 40.00 X 312499 0 47571 ARMANDO MAGANA MD DIRECTOR 40.00 X 964291 0 58015 JOSEPH MARGHEIM MD DIRECTOR 40.00 X 419480 0 57635 DORISA POLK MD DIRECTOR 40.00 2.00 X 473792 0 55644 MARK SCANLAN MD DIRECTOR 40.00 X 344613 0 56480 JASON WALSH DIRECTOR (THRU 7/2018) 40.00 X 614784 0 45687 SHIRLEY GOMPERT SECRETARY (THRU 7/2018) 40.00 X 14534 0 9580 KAYLA MISNER SECRETARY 40.00 X 25277 0 16047 ROMMIE HUGHES MD PHYSICIAN 40.00 X 890987 0 59240 JASON LATOWSKY MD PHYSICIAN 40.00 X 834932 0 56311 MATTHEW BRUNER MD PHYSICIAN 40.00 2.00 X 524758 0 56614 TIMOTHY FRIEDLEIN MD PHYSICIAN 40.00 X 1010760 0 42016 RAQEEB HAQUE PHYSICIAN 40.00 X 846079 0 29385 OMAR JIMENEZ PHYSICIAN 40.00 X 689811 0 49810 JEFFREY SALISBURY PHYSICIAN 40.00 X 504968 0 59223 JOHN BLOMSTEDT PHYSICIAN 40.00 X 494184 0 56187 12237361 848539 1230678 83 0 1 0 COMPHEALTH ASSOCIATES INC PO BOX 972670 DALLAS TX 75397 MEDICAL SERVICES 2601622 RURAL PARTNERS IN MEDICINE PO BOX 772519 STEAMBOAT SPRINGS CO 80477 MEDICAL SERVICES 1678553 HEALTH MOUNT LLC 1326 MONTGOMERY LN SOUTHLAKE TX 76092 MEDICAL SERVICES 953058 GLOBAL HOSPITALIST SOLUTIONS 5865 RIDGEWAY CENTER PARKWAY MEMPHIS TN 38120 MEDICAL SERVICES 883787 LOCUMTENENSCOM PO BOX 405547 ATLANTA GA 30384 MEDICAL SERVICES 852038 22 32659200 34750 32693950 PHYSICIAN SERVICES 621110 36183323 36183323 CONSULTING SERVICES 621110 6167274 6167274 36464 36464 42387061 640 640 55246 37482 17764 17764 75099415 42387061 17764 640 X 29928 29928 9493073 9493073 31365650 29358168 2007482 852130 798880 53250 5735883 5033663 702220 2191685 1891923 299762 39940 413 39527 86580 86580 14545134 12681534 1863600 57667 6491 51176 1092206 1092206 274416 274416 1832411 1721572 110839 152581 143381 9200 2753 2753 227966 222299 5667 454057 447019 7038 MEDICAL EXPENSES 3585530 3585443 87 CORPORATE ALLOCATION 2044488 2044488 DUES & LICENSES 232710 157684 75026 LABORATORY EXPENSES 90229 90229 74387017 67031075 7355942 0 140203 18012 3352874 6436404 319976 289777 102523 212805 4191879 3457163 622033 734716 77631 1004882 4615240 8696596 5177129 4818019 0 3728068 5177129 8546087 X -561889 150509 -561889 150509 4615240 8696596 712398 0 X X 0 1 X 1 0 X 22959200 23359200 32693950 79012350 52383813 53716029 52147499 44101030 42387061 244735432 52383813 53716029 75106699 67460230 75081011 323747782 0 0 0 323747782 -1970 566 966 640 202 -1970 566 966 640 202 174130 117528 77890 38114 17764 425426 90929 344570 304246 77620 817365 52648872 54176157 75489401 67576930 75099415 324990775 0.99620 0.00000 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 4551048 538883 -191365 61231 4837335 4507319 106517 296128 358916 4551048 4546780 153000 72629 265090 4507319 4853177 255505 -56366 505590 4546726 5289569 452644 179311 1068347 4853177 0.24700 0.75300 0 1 1 194446 125996 68450 3940001 3274161 665840 57432 57006 426 734716 PATIENT CUSTOMER CONTRACTS 1004882 1004882 DUE TO AFFILIATES 3728068 3728068 X PART V, LINE 4: ENDOWMENT FUNDS ARE RESTRICTED BY DONORS FOR HEALTHCARE RESEARCH, HEALTHCARE EDUCATION SCHOLARSHIPS, AND FOR CAPITAL PROJECTS. PART X, LINE 2: REGIONAL WEST HEALTH SERVICES (RWHS), REGIONAL WEST MEDICAL CENTER, REGIONAL WEST FOUNDATION, REGIONAL WEST VILLAGE, REGIONAL WEST PHYSICIAN CLINICS (RWPC) AND REGIONAL WEST GARDEN COUNTY (RWGC) ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND HAVE RECEIVED DETERMINATION LETTERS THAT THEY ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE INTERNAL REVENUE CODE. THE MEDICAL CENTER HAS REALIZED CERTAIN INCOME WHICH THE INTERNAL REVENUE SERVICE CONSIDERS TO BE UNRELATED BUSINESS INCOME SUBJECT TO INCOME TAX. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX EXEMPT STATUS. REGIONAL CARE, INC. (RCI) IS A FOR-PROFIT CORPORATION AND FILES A SEPARATE FEDERAL INCOME TAX RETURN. A PROVISION FOR INCOME TAXES IS PROVIDED FOR THOSE ACTIVITIES THAT CREATE TAXABLE INCOME. RCI RECOGNIZED FEDERAL AND STATE INCOME TAX EXPENSE OF APPROXIMATELY $681 AND $2,953 IN 2018 AND 2017, RESPECTIVELY. THE INCOME TAX EXPENSE IS INCLUDED IN SUPPLIES AND OTHER EXPENSES IN THE CONSOLIDATED STATEMENTS OF OPERATIONS. RWHS ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740 INCOME TAXES. RWHS RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2018 AND 2017, RWHS HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 REGIONAL WEST FOUNDATION 4021 AVENUE B SCOTTSBLUFF NE 69361 237171022 501(C)(3) 5574 GENERAL OPERATIONS SCOTTSBLUFF COUNTY AGRICULTURAL SOCIETY 130625 CO RD E MITCHELL NE 69357 470393360 501(C)(5) 5563 GENERAL OPERATIONS 1 1 PART I, LINE 2: ALL GRANTS MUST BE APPROVED BY MANAGERS AND/OR THE BOARD OF DIRECTORS DEPENDING ON THE AMOUNT TO BE GIVEN. X 1 1 0 1 0 0 0 0 0 0 0 VINCENT BJORLING MD CHAIR 354594 0 216540 0 2487 0 11000 0 35482 0 620103 0 0 0 DAVID HOLDT MD PRESIDENT 397245 0 0 0 193461 0 11800 0 35472 0 637978 0 0 0 JOHN MENTGEN CEO 0 509882 0 0 0 9273 0 70118 0 46325 0 635598 0 0 MICHAEL ICKOWSKI TREASURER/CFO 0 305004 0 15000 0 9380 0 58410 0 17694 0 405488 0 0 SEROZAN AMROLIWALLA MD DIRECTOR 265982 0 0 0 211 0 7892 0 17753 0 291838 0 0 0 BRENT ELLISON MD DIRECTOR 474320 0 0 0 436 0 11000 0 45291 0 531047 0 0 0 MARK HARTMAN MD DIRECTOR 649604 0 0 0 2322 0 8261 0 42070 0 702257 0 0 0 JEFFREY HOLLOWAY MD DIRECTOR 575669 0 137483 0 1258 0 11000 0 45665 0 771075 0 0 0 KENT LACEY MD DIRECTOR 297863 0 13665 0 971 0 9287 0 38284 0 360070 0 0 0 ARMANDO MAGANA MD DIRECTOR 712990 0 247737 0 3564 0 11000 0 47015 0 1022306 0 0 0 JOSEPH MARGHEIM MD DIRECTOR 418976 0 0 0 504 0 11000 0 46635 0 477115 0 0 0 DORISA POLK MD DIRECTOR 358692 0 114557 0 543 0 11000 0 44644 0 529436 0 0 0 MARK SCANLAN MD DIRECTOR 202653 0 141510 0 450 0 11000 0 45480 0 401093 0 0 0 JASON WALSH DIRECTOR (THRU 7/2018) 476292 0 137817 0 675 0 11000 0 34687 0 660471 0 0 0 ROMMIE HUGHES MD PHYSICIAN 669287 0 219378 0 2322 0 11000 0 48240 0 950227 0 0 0 JASON LATOWSKY MD PHYSICIAN 538176 0 296322 0 434 0 11000 0 45311 0 891243 0 0 0 MATTHEW BRUNER MD PHYSICIAN 430565 0 93730 0 463 0 11000 0 45614 0 581372 0 0 0 TIMOTHY FRIEDLEIN MD PHYSICIAN 452482 0 556193 0 2085 0 11000 0 31016 0 1052776 0 0 0 RAQEEB HAQUE PHYSICIAN 845500 0 0 0 579 0 11000 0 18385 0 875464 0 0 0 OMAR JIMENEZ PHYSICIAN 688672 0 0 0 1139 0 3744 0 46066 0 739621 0 0 0 JEFFREY SALISBURY PHYSICIAN 504423 0 0 0 545 0 11000 0 48223 0 564191 0 0 0 JOHN BLOMSTEDT PHYSICIAN 290942 0 202942 0 300 0 11000 0 45187 0 550371 0 0 0 PART I, LINE 1A IN THE CURRENT YEAR, REGIONAL WEST HEALTH SERVICES, A RELATED TAX-EXEMPT ENTITY, PAID FOR ONE MONTH OF A MEMBERSHIP TO THE YMCA FOR ANY EMPLOYEE WHO CHOSE TO ENROLL. THIS AMOUNT WAS TREATED AS TAXABLE COMPENSATION TO THE EMPLOYEE. DIRECTORS, OFFICERS AND HIGHEST COMPENSATED EMPLOYEES WHO RECEIVED THIS BENEFIT ARE MICHAEL ICKOWSKI, DAVID HOLDT, RAQEEB HAQUE, JEFFREY SALISBURY AND JEFFREY HOLLOWAY. PART I, LINE 3 THE CEO AND CFO ARE COMPENSATED BY REGIONAL WEST HEALTH SERVICES, A RELATED ORGANIZATION. METHODS USED TO ESTABLISH COMPENSATION FOR THESE INDIVIDUALS INCLUDE THE FOLLOWING: COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, COMPENSATION SURVEY OR STUDY AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. PART I, LINE 4B THE FOLLOWING INDIVIDUALS PARTICIPATED IN A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN: JOHN MENTGEN 59,118 MICHAEL ICKOWSKI 47,410 DAVID HOLDT 800 FORM 990, PART VI, SECTION A, LINE 6 THE CORPORATION'S SOLE MEMBER IS REGIONAL WEST HEALTH SERVICES. FORM 990, PART VI, SECTION A, LINE 7A REGIONAL WEST HEALTH SERVICES (RWHS), THE SOLE MEMBER, APPOINTS 3 EX-OFFICIO VOTING DIRECTORS TO THE BOARD: THE PRESIDENT AND CEO OF RWHS, THE CFO OF RWHS, AND THE PRESIDENT OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7B REGIONAL WEST HEALTH SERVICES (RWHS), THE SOLE MEMBER, MUST APPROVE ALL MATTERS PERTAINING TO THE MERGER, CONSOLIDATION, LIQUIDATION OR AMENDMENT TO THE ARTICLES OF INCORPORATION OR BYLAWS OF THE CORPORATION AS WELL AS ANY PROPOSAL TO SELL, LEASE, EXCHANGE, MORTGAGE, PLEDGE OR DISPOSE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE CORPORATION SHALL BE SUBMITTED TO THE VOTE OF THE SOLE VOTING MEMBER. THE ANNUAL BUDGET OF THE CORPORATION IS ALSO SUBJECT TO THE APPROVAL OF RWHS. FORM 990, PART VI, SECTION B, LINE 11B THE BOARD WILL HAVE AN OPPORTUNITY TO REVIEW DRAFTS ELECTRONICALLY PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ENFORCEMENT OF CONFLICTS POLICY ANNUAL DISCLOSURE BY BOARD MEMBERS OF ANY CONFLICT OF INTEREST, AS SET FORTH IN THE POLICIES, IS REQUIRED. FOR ANY POSSIBLE CONFLICT OF INTEREST IDENTIFIED, THE REMAINING BOARD DETERMINES IF IT ACTULLY CONSTITUTES A CONFLICT OF INTEREST WITHOUT THE CONFLICTED BOARD MEMBER PRESENT. IF A CONFLICT OF INTEREST IS DETERMINED TO EXIST, THE BOARD, LESS THE CONFLICTED MEMBER, WILL THEN DECIDE THE LEVEL OF INVOLVEMENT OF THE MEMBER IN DECISION MAKING FOR THE ENTITY, IF THERE IS AN ALTERNATIVE ARRANGEMENT THAT WILL ELIMINATE THE CONFLICT OF INTERSET, AND THE APPROPRIATENESS OF THE CONFLICTED MEMBER CONTINUING AS A BOARD MEMBER. FAILURE TO DISCLOSE A CONFLICT OF INTEREST CAN RESULT IN DISCIPLINARY AND CORRECTIVE ACTION FOR THE CONFLICTED MEMBER. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION PROCESS FOR TOP OFFICIAL: COMPENSATION FOR THE COO IS DETERMINED BY THE COMPENSATION COMMITTEE OF THE RWHS BOARD. THE DETERMINATION IS BASED ON MARKET DATA AND RECOMMENDATIONS FROM AN INDEPENDENT CONSULTING FIRM WHO COLLECTS THAT INFORMATION FOR COMPARISON PURPOSES. MINUTES ARE KEPT OF THESE MEETINGS. COMPENSATION PROCESS FOR OFFICERS: COMPENSATION FOR THE CEO AND KEY EMPLOYEES IS REVIEWED BY AN INDEPENDENT CONSULTANT ON AN ANNUAL BASIS TO ENSURE THE COMPENSATION PLAN MEETS REASONABLENESS TESTING COMPARED TO MGMA COMPENSATION SURVEY. THE COMPENSATION MODEL IS ALSO REVIEWED BY LEGAL COUNSEL FOR REASONABLENESS AND COMPLIANCE WITH IRS REQUIREMENTS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 12,681,534. MANAGEMENT AND GENERAL EXPENSES 1,863,600. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 14,545,134. FORM 990, PART XII, LINE 2C: THE CFO OF REGIONAL WEST HEALTH SERVICES, THE SOLE MEMBER OF THE ORGANIZATION, IS RESPONSIBLE FOR OVERSIGHT OF THE AUDIT AND SELECTION OF THE INDEPENDENT PUBLIC ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. REGIONAL WEST HEALTH SERVICES 4021 AVENUE B SCOTTSBLUFF NE 69361 363314157 ADMIN SUPPORT NE 501(C)(3) LINE 12B, II N/A 0 REGIONAL WEST MEDICAL CENTER 4021 AVENUE B SCOTTSBLUFF NE 69361 470385129 HOSPITAL NE 501(C)(3) LINE 3 REGIONAL WEST HEALTH SERVICES 0 REGIONAL WEST GARDEN COUNTY 4021 AVENUE B SCOTTSBLUFF NE 69361 391904975 CAH NE 501(C)(3) LINE 3 REGIONAL WEST HEALTH SERVICES 0 REGIONAL WEST FOUNDATION 4021 AVENUE B SCOTTSBLUFF NE 69361 237171022 FUNDRAISING NE 501(C)(3) LINE 12A, I REGIONAL WEST HEALTH SERVICES 0 REGIONAL WEST VILLAGE 4021 AVENUE B SCOTTSBLUFF NE 69361 363314162 RETIREMENT FACILITY NE 501(C)(3) LINE 10 REGIONAL WEST HEALTH SERVICES 0 REGIONAL WEST HEALTH SERVICES & AFFILIATES 4021 AVENUE B SCOTTSBLUFF NE 69361 470658690 HEALTH PLAN NE 501(C)(9) REGIONAL WEST HEALTH SERVICES 0 REGIONAL CARE INC 4021 AVENUE B SCOTTSBLUFF NE 69361 470760050 TPA NE N/A C 0 0 1 1 0 1 0 0 0 0 0 1 0 0 1 1 1 1 1 0 REGIONAL WEST HEALTH SERVICES & AFFILIATE R 6052471 CASH