2019-04-11T09:01:36-05:00 2018-06-30 430352985 KERBER ECK & BRAECKEL LLP 3401 OFFICE PARK DRIVE MARION IL 62959 990 2017-07-01 370661202 FAIRFIELD MEMORIAL HOSPITAL ASSOC FAIR 6188422611 303 NW 11TH STREET FAIRFIELD IL 62837 KATHERINE BUNTING CEO 6188422611 2019-04-08 1 ANNA GUETERSLOH P01315485 6189938724 2019-04-04 66.186.110.114 2019-04-08 12:58:38 CD P 8FBDAAF724FD1D6222B37EDFD135E9DD0FF3B3E7 6EF7521281B15B6F89C09861DE9D9A86F4FF6B67 2017 2019-02-21 02:37:17Z KATHERINE BUNTING 31534552 0 X WWW.FAIRFIELDMEMORIAL.ORG X 1943 IL THE MISSION OF FAIRFIELD MEMORIAL HOSPITAL IS TO MAINTAIN AND IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. 9 7 390 62 0 0 225461 106077 28392655 30007433 14992 163360 940653 1257682 29573761 31534552 0 0 0 0 14976503 16340709 0 0 0 13903381 14367649 28879884 30708358 693877 826194 24311637 24105006 8931291 8054433 15380346 16050573 X THE MISSION OF FAIRFIELD MEMORIAL HOSPITAL IS TO MAINTAIN AND IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. 0 0 30708358 31428475 AS A NOT-FOR-PROFIT COMMUNITY HOSPITAL, FAIRFIELD MEMORIAL HOSPITAL IS A CHARITABLE ORGANIZATION THAT EXISTS TO ADVANCE THE HEALTH OF THE RESIDENTS OF WAYNE COUNTY AND SURROUNDING COMMUNITIES. FAIRFIELD MEMORIAL HOSPITAL OPERATES A RURAL HEALTHCARE FACILITY WITH 25 ACUTE CARE BEDS AND 30 SKILLED CARE BEDS. IN AUGUST 2008 THE HOPSITAL OPENED AN OUTPATIENT PHYSICIAN CLINIC. FAIRFIELD MEMORIAL HOSPITAL PROVIDES QUALITY MEDICAL HEALTHCARE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORGIN, HANDICAP, AGE OR ABILITY TO PAY. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION AND STABILITY OF FAIFIELD MEMORIAL HOSPITAL, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE ESSENTIAL MEDICAL SERVICES. THEREFORE, IN KEEPING WITH THIS CORPORATION'S COMMITMENT TO SERVE ALL MEMBERS OF THE COMMUNITY, FREE CARE AND/OR SUBSIDIZED CARE,CARE PROVIDED TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS AT BELOW COST,AND HEALTH ACTIVITIES AND PROGRAMS TO SUPPORT THE COMMUNITY WILL BE CONSIDERED WHERE THE NEED AND/OR INDIVIDUALS INABILITY TO PAY COEXISTS. THE COMMUNITY BENEFITS CAN BE MEASURED IN MANY WAYS INCLUDING: DIRECT PATIENT CARE, SCREENINGS, EDUCATION, FUNDRAISING, AND COMMUNITY SERVICE EFFORTS OF OUR COLLEAGUES. THE HOSPITAL PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS, PROVIDING SERVICES TO BOTH MEDICARE AND MEDICAID PATIENTS. CHARITY CARE IS ALSO PROVIDED THROUGH THE HOSPITAL'S INTERNAL POLICY. 30708358 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 0 0 1 35 0 390 1 0 0 0 0 0 0 0 0 X 9 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X AMY MARSH 6188478260 303 NW 11TH ST FAIRFIELD IL 62837 PATRICK MOLT MD PRESIDENT 40.00 X 57713 0 0 JOSEPH HUNGERFORD VICE PRESIDENT 2.00 X 0 0 0 ANITA POND SECRETARY/TREASURER 2.00 X 0 0 0 CLARK GRIFFITH TRUSTEE 1.00 X 0 0 0 DONNA MASTERSON TRUSTEE 1.00 X 0 0 0 JAMIE POLLARD TRUSTEE 1.00 X 0 0 0 SANDY SIMPSON TRUSTEE 1.00 X 0 0 0 JARED VAUGHN TRUSTEE 2.00 X 0 0 0 DOUG WILSON TRUSTEE 1.00 X 0 0 0 KATHERINE BUNTING CEO 40.00 X 250667 0 11628 AMY MARSH CURRENT CFO 40.00 X 97375 0 5456 TRACY TAYLOR CNO 40.00 X 85816 0 1640 WESLEY THOMPSON PHYSICIAN 40.00 X 376981 0 27356 CHRISTOPHER BALLARD PHYSICIAN 40.00 X 299359 0 27974 ALEXIS KING CRNA 40.00 X 240214 0 11878 KIMBERLY KING CRNA 40.00 X 194533 0 16791 NICOLE FYIE PHYSICIAN 40.00 X 205846 0 21543 MARLA LAFIKES PHYSICIAN 40.00 X 254554 0 27148 2063058 0 151414 7 0 1 0 DR RODNEY BEELER 2142 KETTLES HILL COURT EVANSVILLE IN 477258266 ER PHYSICIAN 390731 DOUGLAS FRANKEL 407 S MARKET ST MARION IL 62959 ER PHYSICIAN 356655 MICHELLE O'NEILL 10345 WILMINGTON DRIVE EVANSVILLE IN 47577 ER PHYSICIAN 305730 SCOTT ROUSTIO 8422 BROESWOOD ESTATES DRIVE OFALLON IL 622694235 ER PHYSICIAN 249210 4 40042 66035 106077 NET PATIENT SERVICE REVENUE 30007433 30007433 30007433 163360 163360 205008 0 205008 205008 205008 MISCELLANEOUS 402367 402367 304B REBATE 302996 302996 CAFETERIA SERVICES 177871 177871 169440 169440 1052674 31534552 31428475 0 0 X 510295 510295 12567100 12567100 123520 123520 2222375 2222375 917419 917419 39960 39960 5375766 5375766 219207 219207 1551383 1551383 1223568 1223568 176463 176463 432624 432624 1426953 1426953 181872 181872 DRUGS 1271969 1271969 MEDICAL SUPPLIES 902831 902831 BED AND PROVIDER TAX AM 682783 682783 REPAIRS AND MAINTENANCE 494218 494218 388052 388052 30708358 30708358 0 0 1346 1611 2085961 3918888 5795885 4000323 60524 7044 1006545 1027168 421313 618239 435860 511164 38625884 25260921 13904335 13364963 800 800 599068 654806 24311637 24105006 1695826 1644601 335188 165747 6097512 5466816 422765 777269 380000 0 8931291 8054433 X 15021824 15848027 357953 201977 569 569 15380346 16050573 24311637 24105006 X 826194 -155967 X 0 1 X 1 0 X 449428 449428 20506334 10618863 9887471 17437519 14596133 2841386 232603 45925 186678 13364963 X 31378585 -155967 -155967 31534552 0 31534552 30708358 0 30708358 0 30708358 PART X, LINE 2: THERE WERE NO PENALTIES, INTEREST, OR UNCERTAIN TAX BENEFITS DETERMINED AND RECORDED AS A LIABILITY. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN TEMPORARILY RESTRICTED NET ASSETS 1 1 1 X 1 X 1 1 0 0 501459 501459 0.01630 4814420 682782 4131638 0.13450 5315879 682782 4633097 0.15080 5315879 682782 4633097 0.15080 1 1035449 258862 13331147 15331388 -2000241 X 1 1 1 1 FAIRFIELD MEMORIAL HOSPITAL 303 NW 11TH STREET FAIRFIELD IL 62837 WWW.FAIRFIELDMEMORIAL.ORG 320005545 X X X X FAIRFIELD MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X 16 1 0 0 1 X WWW.FAIRFIELDMEMORIAL.ORG X 1 16 1 WWW.FAIRFIELDMEMORIAL.ORG 0 1 X 200.000000000000 300.000000000000 X X 1 1 X X X X 1 X WWW.FAIRFIELDMEMORIAL.ORG X WWW.FAIRFIELDMEMORIAL.ORG X WWW.FAIRFIELDMEMORIAL.ORG X X X X X X X 1 X 0 X X X X 1 X 0 0 1 1 - HORIZON HEALTHCARE 213 NW 10TH STREET SUITE A FAIRFIELD IL 62837 OUTPATIENT PHYSICIAN CLINIC PART I, LINE 7: THE FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION USED A COST TO CHARGE RATIO AS CALCULATED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES, INCLUDED IN THE SCHEDULE H INSTRUCTIONS TO DETERMINE THE AMOUNTS ON LINES 7A AND 7B OF PART I OF SCHEDULE H. PART III, LINE 2: THE HOSPITAL CALCULATED BAD DEBT EXPENSE AT COST USING THE COST TO CHARGE RATIO AS CALCULATED USING WORKSHEET 2 OF THE SCHEDULE H INSTRUCTIONS. PATIENT ACCOUNTS ARE WRITTEN OFF TO BAD DEBT ONLY AFTER ALL COLLECTION PROCEDURES HAVE BEEN EXHAUSTED AS OUTLINED IN SCHEDULE H, PART III, LINE9B. PATIENT ACCOUNTS ARE WRITTEN OFF TO BAD DEBT AFTER ALL DISCOUNTS AND PAYMENTS HAVE BEEN APPLIED. PART III, LINE 3: BASED ON THE HOSPITAL'S EXPERIENCE WITH ALL ITS PATIENTS, THEY ESTIMATE THAT IT IS LIKELY THAT UP TO ONE FOURTH OF THE PATIENT ACCOUNTS WRITTEN OFF TO BAD DEBTS MAY QUALIFY FOR CHARITY CARE OR OTHER ASSISTANCE BUT CHOSE NOT TO APPLY. THEREFORE, 25% OF THE BAD DEBT EXPENSE WAS INCLUDED ON PART III, LINE 3 AT COST. PART III, LINE 4: NOTE S - UNCOMPENSATED CARE AND COMMUNITY BENEFIT IN SUPPORT OF ITS MISSION, THE HOSPITAL VOLUNTARILY PROVIDES CARE TO PATIENTS AT LESS THAN ITS ESTABLISHED CHARGES FOR PATIENTS THAT MEET THE HOSPITAL'S CHARITY CARE CRITERIA. BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED IN NET PATIENT SERVICES REVENUE.IN ADDITION, THE HOSPITAL PROVIDES SERVICES TO OTHER MEDICALLY INDIGENT PATIENTS UNDER CERTAIN GOVERNMENT-REIMBURSED PUBLIC AID PROGRAMS. SUCH PROGRAMS PAY PROVIDERS AMOUNTS WHICH ARE LESS THAN ESTABLISHED CHARGES FOR THE SERVICES PROVIDED TO THE RECIPIENTS AND MANY TIMES THE PAYMENTS ARE LESS THAN THE COST OF RENDERING THE SERVICES PROVIDED. THE HOSPITAL'S TOTAL COST OF UNCOMPENSATED CARE RELATING TO THESE SERVICES AND OTHER SERVICES ARE AS FOLLOWS: 2018 2017 CHARITY CARE $ 485,585 $ 81,886 STATE MEDICAID AND OTHER PUBLIC PROGRAMS $ 4,976,028 $ 1,441,303 UNCOLLECTIBLE ACCOUNTS $ 816,292 $ 651,093 THE UNCOMPENSATED CARE COST OF STATE MEDICAID AND OTHER PUBLIC AID PROGRAMS IS DETERMINED BY COMPUTING THE COST OF PROVIDING THAT CARE LESS AMOUNTS PAID BY THE PROGRAM.IN ADDITION TO THE ABOVE COST OF UNCOMPENSATED CARE, THE HOSPITAL ALSO COMMITS SIGNIFICANT TIME AND RESOURCES TO ENDEAVORS AND CRITICAL SERVICES WHICH MEET OTHERWISE UNFULFILLED COMMUNITY NEEDS. MANY OF THESE ACTIVITIESARE SPONSORED WITH KNOWLEDGE THAT THEY WILL NOT BE SELF-SUPPORTING ORFINANCIALLY VIABLE. PART III, LINE 8: UNPAID COST OF MEDICARE REPRESENTS THE COST (DETERMINED USING THE OVERALL COST TO CHARGE RATIO) OF PROVIDING SERVICES TO PRIMARILY ELDERLY BENEFICIARIES OF THE MEDICARE PROGRAM, IN EXCESS OF PAYMENTS FOR THOSE SERVICES. IRS REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENT HEALTH BENEFTIS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THIS IMPLIES THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT. PART III, LINE 9B: THE FAIRFIELD MEMORIAL HOSPITAL APPLIES ITS COLLECTION PRACTICES EQUALLY TO ALL PATIENTS, BOTH CHARITY CARE ELIGIBLE AND NON-CHARITY CARE PATIENTS. THE PROCEDURES FOR COLLECTION ON PATIENT ACCOUNTS ARE AS FOLLOWS:SELF-PAY ACCOUNTS AND ACCOUNTS WITH BALANCES AFTER INSURANCE ARE SENT A LETTER REQUESTING PAYMENT. IF NO RESPONSE IS RECEIVED WITHIN 35 DAYS, THE ACCOUNT IS TRANSFERRED TO OUR EARLY-OUT DEPARTMENT FOR A FOLLOW-UP STATEMENT/PHONE CALL TO THE PATIENT. THE HOSPITAL OFFERS THE PATIENTS SEVERAL PAYMENT ALTERNATIVES:1. CASH/CHECK FOR THE FULL AMOUNT2. MASTERCARD/VISA/DISCOVER3. SHORT-TERM MONTHLY INSTALLMENTS BASED ON OUTSTANDING BALANCESPECIAL PAYMENT ARRANGEMENTS CAN BE MADE UPON REQUEST AND COMPLETION OF A CREDIT APPLICATION WHICH WILL BE VERIFIED AND APPROVED BY THE BUSINESS OFFICE DIRECTOR. IF PAYMENT OR SATISFACTORY PAYMENT ARRANGMENTS AS OUTLINED ABOVE ARE NOT MADE, THE ACCOUNT WILL PROCEED THROUGH A COLLECTION PROCESS AS FOLLOWS:DAY 1 - 1ST NOTICE SENTDAY 7-14 - FIRST PHONE CALL IS MADE. AT LEAST ONE PHONE CALL OR NOTICE PER WEEK FOR THE REMAINDER OF THE EARLY-OUT 90 DAY PERIODDAY 75 - DEMAND NOTICE IS SENTDAY 90 - ACCOUNT IS SENT TO COLLECTIONS ANY ACCOUNT THAT IS SENT TO COLLECTIONS MAY BE TURNED OVER TO AN ATTORNEY AND ANY ADDITIONAL COSTS ASSOCIATED WITH COLLECTIONS WILL BE ADDED TO THE ACCOUNT BALANCE. PART VI, LINE 2: GENERALLY SPEAKING, THE DETERMINATION OF CURRENT AND FUTURE HEALTH CARE NEEDS OF THE COMMUNITY OR COMMUNITIES SERVED BY FAIRFIELD MEMORIAL HOSPITAL IS BASED ON ALL OR A COMBINATION OF THE FOLLOWING FACTORS; EXISTENCE OR NONEXISTENCE OF SERVICES, OPPORTUNITY, SUPPLY, DEMONSTRATED NEED, "VOICE OF THE CUSTOMER", AND /OR COLLABORATIVE EFFORTS WITH OUTSIDE ENTITIES, GOVERMENT AGENCIES, AND OTHER HEALTH CARE PROVIDERS THAT WOULD ENABLE THEFILLING OF A NEED OR ENHANCE AND COMPLIMENT AN ALREADY EXISTING SERVICE. DATA IS GATHERED CONSTANTLY THROUGH BENCHMARKETING, MARKET RESEARCH, CUSTOMER SURVEYS, PHYSCIAN INPUT, AND THROUGH CONSTANT MONITORING OF STATE AND FEDERAL GUIDELINES. THIS INFORMATION IS REVIEWED AND ANALYZED BY THE HOSPITAL'S SENIOR LEADERSHIP AND INCORPORATED INTO STRATEGIC PLANNING PROCESSES. PART VI, LINE 3: SIGNS ARE POSTED IN THE FACILITY. THE PATIENT'S BILL INFORMS THEM OF FINANCIAL ASSISTANCE PROGRAM. OUR HOSPITAL WEBSITE HAS A LINK TO THE FINANCIAL ASSISTANCE APPLICATION. SOCIAL SERVICE DEPARTMENT SPEAKS TO INPATIENTS ABOUT THE PROGRAM. PART VI, LINE 4: FAIRFIELD MEMORIAL HOSPITAL SERVES THE POPULATIONS OF WAYNE COUNTY AND THE SURROUNDING COMMUNITIES WITHOUT REGARD TO AGE, GENDER, INCOME , ETHNIC ORIGIN, INSURANCE COVERAGE, OR ABILITY TO PAY. WAYNE COUNTY IS A RURAL AREA WITH AN ESTIMATED POPULATION OF 16,495. THE MEDIAN HOUSEHOLD INCOME IN 2016 WAS $46,405, WHICH WAS 75.8% OF ILLINOIS' AVERAGE. THE PERCENTAGE OF INDIVIDUALS BELOW POVERTY LEVEL WAS 14%. PART VI, LINE 7, REPORTS FILED WITH STATES IL 1 X X X X X 0 0 0 0 0 0 0 0 0 KATHERINE BUNTING CEO 250667 0 0 0 0 0 4460 0 7168 0 262295 0 0 0 WESLEY THOMPSON PHYSICIAN 376981 0 0 0 0 0 6083 0 21273 0 404337 0 0 0 CHRISTOPHER BALLARD PHYSICIAN 299359 0 0 0 0 0 5869 0 22105 0 327333 0 0 0 ALEXIS KING CRNA 240214 0 0 0 0 0 4710 0 7168 0 252092 0 0 0 KIMBERLY KING CRNA 194533 0 0 0 0 0 3916 0 12875 0 211324 0 0 0 NICOLE FYIE PHYSICIAN 205846 0 0 0 0 0 2324 0 19219 0 227389 0 0 0 MARLA LAFIKES PHYSICIAN 254554 0 0 0 0 0 5043 0 22105 0 281702 0 0 0 NICOLE FYIE WIFE OF BOARD MEMBER MEDICAL SCHOOL X 267400 7044 0 1 1 7044 PATRICK MOLT PHYSICIAN 57713 BOARD MEMBER 0 NICOLE FYIE PHYSICAIN 225065 WIFE OF BOARD MEMEBER 0 FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WAS REVIEWED BY THE CFO AND FINANCE COMITTEE. AFTER THE FINANCE COMITTEE IT WAS TAKEN TO THE FULL BOARD FOR APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY EACH BOARD MEMBER RECEIVES THE CORPORATE COMPLIANCE POLICY WHICH INCLUDES THE CONFLICT OF INTEREST POLICY WITHIN IT TO REVIEW AND SIGN THAT THEY HAVE READ THE POLICY AND HAVE NO COMFLICTS. ALL SIGNED DOCUMENTS AREKEPT ON FILE IN ADMINISTRATION OFFICE. FORM 990, PART VI, SECTION B, LINE 15 THE CEO'S COMPENSATION PROCESS INVOLVES ALLIANT, THE HOSPITAL'S MANAGEMENT COMPANY, BRINGING EVALUATION TIME SALARY INFORMATION FOR OTHER ALLIANT HOSPITALS WHICH INCLUDE HOSPITAL'S IN THE FOLLOWING STATES: ILLINOIS, KENTUCKY, AND INDIANIA; AS WELL AS SALARY INFORMATION FOR CEO'S FROM OTHERHOSPITAL'S IN RELEVANT SIZE (IN REVENUES) TO FMH. THE SALARY COMPARISON INFORMATION IS PRESENTED TO THE PERSONNEL COMMITTEE OF THE BOARD IN WHICH THEY REVIEW THE INFORMATION AND ESTABLISH THE RATE FOR THE CEO. MARKET WAGE DATA FOR THE HEALTHCARE INDUSTRY IS REVIEWED FOR COMPARABLERATES FROM THREE SALARY SURVEYS INCLUDING ALLIANT AS ONE. THE CEO DETERMINES THE AMOUNTS FOR THE OFFICERS. FORM 990, PART VI, SECTION C, LINE 19 COPIES OF THE ORGANIZATIONS GOVERING DOCUMENTS, CONFLICT OF INTEREST POLICIES, FINANCIAL STATEMENTS, AND THE FEDERAL FORM 990 TAX RETURN ARE AVAILABLE UPON REQUEST FROM THE ADMINISTRATIVE OFFICES. FORM 990, PART IX, LINE 11G PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 3,624,749. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,624,749. PHYSICIANS FEES: PROGRAM SERVICE EXPENSES 1,751,017. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,751,017. FORM 990, PART XI, LINE 9: CHANGE IN TEMPORARILY RESTRICTED NET ASSETS -155,967. FORM 990, PART 1, LINE 6 VOLUNTEERS ARE PART OF THE HOSPITAL AUXILIARY WHO RUN FUNDRAISERS ON BEHALF OF THE HOSPITAL AND OPERATE THE GIFT SHOP. FAIRFIELD MEMORIAL HOSPITAL FOUNDATION 303 NW 11TH STREET FAIRFIELD IL 62837 371185754 SUPPORT IL 501C3 LINE 12B, II N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0