2019-10-28T11:59:03-05:00 2018-12-31 351178661 BLUE & CO LLC 500 N MERIDIAN ST SUITE 200 INDIANAPOLIS IN 46204 990 2018-01-01 340719172 BARNESVILLE HOSPITAL ASSOCIATION INC DBA BARNESVILLE HOSPITAL BARN 7404253941 639 W MAIN STREEET BARNESVILLE OH 43713 WILLIE COOPER-LOHR CFO 7404253941 2019-10-21 1 MARGOT BURKE P01588992 3176334705 2019-09-25 47.227.233.166 2019-10-21 22:38:24 ED P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 B19D0506B86ED19F1A0FD2AFEEB91090E576B51F 2018 2019-02-21 02:37:17Z WILLIE COOPER-LOHR 639 W MAIN STREEET BARNESVILLE OH 43713 18447092 0 X WWW.BARNESVILLEHOSPITAL.COM X 1940 OH WE SERVICE THE HEALTH NEEDS OF THE COMMUNITY AND SURROUNDING COUNTIES. OUR COUNTY TO THE SOUTH OF US DOES NOT HAVE A HOSPITAL. THE COMMUNITY IS SERVICED WITH A 24 HOUR EMERGENCY DEPARTMENT, ACUTE INPATIENT SERVICES ALONG WITH SWING BED TO HELP THEM REMAIN CLOSE TO THEIR FAMILIES. WE ALSO HAVE A FULL SERVICE OUTPATIENT SERVICE. 13 10 310 160 0 13931 864698 648955 17920246 17671938 52575 -199697 316937 227253 19154456 18348449 0 1038095 0 0 11685809 11392566 0 0 0 7785337 7401064 19471146 19831725 -316690 -1483276 13925055 12285426 7474436 7590962 6450619 4694464 X BARNESVILLE HOSPITAL ASSOCIATION, INC. OPERATES IN A MANNER CONSISTENT WITH THE REQUIREMENTS OF REV RUL 69-545, THROUGH IT'S PROVISION OF HEALTH CARE SERVICES TO THE COMMUNITY, REGARDLESS OF ABILITY TO PAY. OUR MISSION IS TO IMPROVE THE COMMUNITY'S HEALTH THROUGH THE EFFICIENT PROVISION, COORDINATION AND INTEGRATION OF QUALITY HEALTH SERVICES, HEALTH EDUCATION AND RESEARCH. WE ALSO PROVIDE COMPASSIONATE, QUALITY HEALTH SERVICES ACCORDING TO THE PHYSICAL, SPIRITUAL, PHYCHOLOGICAL, SOCIAL, RELIGIOUS, ENVIRONMENTAL AND ECONOMIC NEEDS OF OUR COMMUNITIES. 0 0 17565964 1038095 17671938 IN 2018 BARNESVILLE HOSPITAL PROVIDED CARE FOR 648 INPATIENT ADMISSIONS RESULTING IN 2,055 PATIENT DAYS. WE ALSO PROVIDED 24,161 OUTPATIENT VISITS PLUS 7,706 EMERGENCY ROOM VISITS. BARNESVILLE HOSPITAL IS A CRITICAL ACCESS HOSPITAL AND PROVIDES EXTENSIVE INPATIENT AND OUTPATIENT CARE FOR MEMBERS OF THE COMMUNITY REGARDLESS OF THEIR ABILITY TO PAY. 17565964 1 1 0 1 0 0 0 0 0 0 1 0 1 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 1 52 0 1 310 1 0 0 0 0 0 0 0 0 0 0 0 0 X 13 10 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X WILLIE COOPER-LOHR 7404253941 639 W MAIN STREEET BARNESVILLE OH 43713 R MELVIN MILBURN PRESIDENT 1.00 0.00 X X 0 0 0 KENT GALLAGHER VICE PRESIDENT 1.00 0.00 X X 0 0 0 C J BRADFIELD TREASURER 1.00 0.00 X X 0 0 0 AARON BRUGGEMAN BOARD MEMBER 1.00 0.00 X 0 0 0 WILLIAM E FRANK JR BOARD MEMBER 1.00 0.00 X 0 0 0 ANGELA HANNAHS BOARD MEMBER 1.00 0.00 X 0 0 0 DAVID HILLIARD DO BOARD MEMBER 40.00 0.00 X 132440 0 25794 MINDY JOHNSON BOARD MEMBER 1.00 0.00 X 0 0 0 TOM JOHNSON BOARD MEMBER 1.00 0.00 X 0 0 0 KENNETH PHILLIPS BOARD MEMBER 1.00 0.00 X 0 0 0 DR SHAUN ROE BOARD MEMBER-TERM BEGAN SEP'18 1.00 39.00 X 0 274746 42046 P K SOURI MD BOARD MEMBER 1.00 39.00 X 0 220014 18632 DELORES WELLS BOARD MEMBER 1.00 0.00 X 0 0 0 DR RUSSELL LEE-WOOD BOARD MEMBER JAN-JUN'18 1.00 0.00 X 0 0 0 CHARLES BARDALL BOARD MEMBER-TERM ENDED JUN'18 1.00 0.00 X 0 0 0 MELISSA HARTSHORN SECRETARY 40.00 0.00 X 43324 0 34290 DAVID PHILLIPS CEO 38.00 2.00 X 146727 0 35559 WILLIE COOPER - LOHR CFO 38.00 2.00 X 100728 0 25599 CYNTHIA TOUVELLE CNO 40.00 0.00 X 118749 0 35126 JOSEPH A JEFFRIES PHARMACIST 40.00 0.00 X 126974 0 23089 MARY B MAZOCH PHARMACIST 40.00 0.00 X 156369 0 27908 825311 494760 268043 6 0 1 0 ALLSCRIPTS HEALTHCARE LLC 24630 NETWORK PLACE CHICAGO IL 60673 COMPUTER SYSTEM SERVICES 861977 NES OHIO INC PO BOX 936451 ATLANTA GA 31193 ER PHYSICIANS 627984 PRECISION ANASTHESIA SERVICES LLC 66325 PLAINFIELD ROAD BELMONT OH 43718 CRNA SERVICES 220470 MEDSTAFF SERVICES LLC PO BOX 1895 POWELL OH 43065 HOSPITALIST SERVICES 177500 LAB CORP PO BOX 12140 BURLINGTON NC 27216 LAB SERVICES 172477 8 422678 209386 16891 648955 NET PATIENT REVENUE 900099 17671938 17671938 17671938 -199697 -199697 78465 98643 -20178 -20178 -20178 CAFETERIA 722210 99431 99431 AUXILIARY INCOME 900099 45846 45846 102154 102154 247431 18348449 17671938 0 27556 X 1038095 1038095 698336 610492 87844 7246346 6334822 911524 263039 231816 31223 2631428 2319078 312350 553417 487726 65691 32747 29238 3509 2464510 2200437 264073 17586 15276 2310 304108 264166 39942 25 22 3 1937004 1706580 230424 21281 17718 3563 18609 12542 6067 63336 63336 501715 312775 188940 174395 174395 DRUGS AND MEDICAL SUPPL 1715704 1715704 DUES & SUB. 99201 86172 13029 AUXILIARY EXPENSES 40586 40586 10257 8910 1347 19831725 17565964 2265761 0 571 571 124401 292441 2629634 2058029 462335 447614 369311 264095 20100238 15851180 4639015 4249058 2994919 2345600 102606 103274 1217426 808319 1384837 1716425 13925055 12285426 2789643 2617216 1620630 1899739 3064163 3074007 7474436 7590962 X 6450619 4694464 6450619 4694464 13925055 12285426 X -1483276 -437984 165105 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 3833 3833 0 PART II-B, LINE 1: A PORTION OF ANNUAL MEMBERSHIP DUES PAID TO TRADE ASSOCIATIONS IS ALLOCATED TO LOBBYING EXPENDITURES. 66199 66199 13448638 10197063 3251575 400235 216936 183299 6185166 5437181 747985 4249058 EQUITY IN BELMONT COUNTY HEALTH SERVICES 808319 F 808319 RELATED PARTY RECEIVABLES 1339104 THIRD PARTY RECEVIABLE 377321 1716425 ACCRUED PENSION COSTS 3074007 3074007 X PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN AND RECOGNIZE A TAX LIABILITY IF AN UNCERTAIN POSITION HAS BEEN TAKEN THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY VARIOUS FEDERAL AND STATE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THESE ENTITIES, AND HAS CONCLUDED THAT AS OF DECEMBER 31, 2018 AND 2017, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE ACCOMPANYING FINANCIAL STATEMENTS. THE ENTITIES ARE SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. SCHEDULE D, PART X, LINE 1 THE HOSPITAL HAS A NON-CONTRIBUTORY DEFINED BENEFIT PENSION PLAN FOR EMPLOYEES WHO MEET CERTAIN REQUIREMENTS AS TO AGE AND LENGTH OF SERVICE. THE PLAN PROVIDES PENSION BENEFITS THAT ARE BASED ON THE EMPLOYEE'S COMPENSATION DURING THEIR PERIOD OF CREDITED SERVICE. 1 1 X 1 X 1 X 1 1 0 1 1 397383 43834 353549 0.01780 2579764 1016143 1563621 0.07880 2977147 1059977 1917170 0.09660 66572 66572 0.00340 1038095 1038095 0.05230 1104667 1104667 0.05570 4081814 1059977 3021837 0.15230 1 1611513 4259534 5612998 -1353464 X 1 1 1 1 BARNESVILLE HOSPITAL ASSOCIATION INC 639 W MAIN ST BARNESVILLE OH 43713 WWW.BARNESVILLEHOSPITAL.COM X BARNESVILLE HOSPITAL ASSOCIATION 1 0 0 1 X X X X X X X X X 16 1 0 0 1 X SEE PART V, PAGE 8 X 1 16 1 SEE PART V, PAGE 8 0 1 X 100.000000000000 250.000000000000 X X X X 1 1 X X X X X 1 X HTTP://WWW.BARNESVILLEHOSPITAL.COM/SERVICES/PATIENT-FINANCIAL-SERVICES/ X HTTP://WWW.BARNESVILLEHOSPITAL.COM/SERVICES/PATIENT-FINANCIAL-SERVICES/ X HTTP://WWW.BARNESVILLEHOSPITAL.COM/SERVICES/PATIENT-FINANCIAL-SERVICES/ X X X X X X X 1 X 0 X X X X 1 X 0 0 BARNESVILLE HOSPITAL ASSOCIATION PART V, SECTION B, LINE 5: MET WITH FOCUS GROUPS FROM DIFFERENT COMMUNITIES (BARNESVILLE, BETHESDA, AND WOODSFIELD). IN ADDITION TO THE COMMUNITY FOCUS GROUPS, AN ADDITIONAL MEETING WAS HELD WITH INDIVIDUALS HAVING A SPECIAL KNOWLEDGE IN PUBLIC HEALTH, COMMUNITY ORGANIZATIONS, AND RESOURCES TO UTILIZE THEIR EXPERTISE AND TO SOLICIT THEIR FEEDBACK. COLLABORATING PARTNERS WITHIN THE COMMUNITY INCLUDED:- THE HEALTH PLAN OF THE UPPER OHIO VALLEY, INC.- BARNESVILLE EXEMPTED VILLAGE SCHOOLS- BELMONT COUNTY EMERGENCY MANAGEMENT AGENCY- OHIO HILLS HEALTH SERVICES- NOBLE COUNTY HEALTH DEPARTMENT- CROSSROADS COUNSELING- BELMONT COUNTY HEALTH DEPARTMENT- BARNESVILLE FIRE DEPARTMENT- ASSISTANT DIRECTOR OF NURSING, BELMONT COLLEGE- BARNESVILLE HOSPITAL FOUNDATION- BARNESVILLE HOSPITAL- BARNESVILLE HOSPITAL- OHIO STATE HEALTH NETWORK- SOUTHEASTERN HOME CARE- ASTORIA PLACE OF BARNESVILLETWO TOWN HALL MEETINGS WERE HELD TO ADDRESS THE TOPIC OF HEROIN ADDICTION. THE TOWN HALL MEETINGS WERE HOSTED BY CROSSROADS COUNSELING, OHIO HILLS HEALTH SERVICES AND BARNESVILLE HOSPITAL. WHILE THESE MEETINGS WERE DIRECTED TOWARD A SPECIFIC ISSUE, THE RESPONSE AND PARTICIPATION IN THE TOWN HALL MEETINGS CONFIRMS THE CONCERN AREA RESIDENTS HAVE REGARDING THE TOPICS OF DRUG ABUSE AND ADDICTION. MEETINGS WERE HELD IN BARNESVILLE, OHIO (250 AREA RESIDENTS ATTENDED) AND IN WOODSFIELD, OHIO (125 AREA RESIDENTS ATTENDED). BARNESVILLE HOSPITAL ASSOCIATION PART V, SECTION B, LINE 11: THE HOSPITAL FACILITY IDENTIFIED SIX SIGNIFICANT NEEDS IN ITS MOST RECENTLY CONDUCTED CHNA. THE NEEDS & THE ACTION TAKEN BY THE HOSPITAL FACILITY TO ADDRESS THE NEEDS DURING 2018 ARE AS FOLLOWS:NUTRITION & WEIGHT STATUS: FACILITATED A WEIGHT LOSS PROGRAM FOR EMPLOYEES TO PROMOTE WELLNESS; THIS INCLUDED INCENTIVES FOR YEARLY PHYSICALS, VOLUNTARY STAFF MONTHLY WEIGH-INS, PROMOTED HEALTHY EATING AND 5K RUN/WALKS.PHYSICAL ACTIVITY: CONDUCTED FITNESS SCREENINGS IN THE COMMUNITY (BODY COMPOSITION ANALYSIS, FLEXIBILITY TESTING, GRIP STRENGTH AND BLOOD PRESSURE).TOBACCO USE: PROVIDED RESOURCES TO EMPLOYEES AND COMMUNITY MEMBERS REGARDING TOBACCO CESSATION STRATEGIES AND PROGRAMS AVAILABLE LOCALLY. EDUCATION:HOSPITAL DIETICIAN OFFERED A HEALTH PROGRAM EMPHASIZING PROPER NUTRITION, THE IMPORTANCE OF EXERCISE AND THE BENEFITS OF SMOKING CESSATION. OFFERED COMMUNITY WELLNESS PROGRAM ON TOPICS PERTINENT TO COMMUNITY MEMBERS.MENTAL HEALTH, DRUGS ABUSE & ALCOHOL IN THE COMMUNITY:PROVIDED DRUG TAKE BACK PROGRAMS ON AN ANNUAL BASIS AS A MEANS TO EDUCATE THE COMMUNITY ON THE NEED TO REDUCE THE AVAILABILITY OF UNWANTED MEDICATION IN THE HOME AND IN THE COMMUNITY AND TO OFFER A SAFE AND CONFIDENTIAL WAY TO DISPOSE OF MEDICATIONS.PROVIDED A DROP BOX IN THE HOSPITAL LOBBY TO ALLOW COMMUNITY MEMBERS A VEHICLE TO DISPOSE OF UNWANTED MEDICATIONS AND SYRINGES ON AN AS NEEDED BASIS.COLLABORATED THROUGH COMMUNITY AND EMS MEETINGS TO PROVIDE EDUCATION REGARDING NARCAN FOR COMMUNITY MEMBERS AND HEALTH CARE PROFESSIONALS AND TO PROVDE NARCAN FREE OF CHARGE THROUGH THE PROJECT DAWN PROGRAM.EXPLORED FEASIBILITY OF OFFERING A MEDICALLY ASSISTED TREATMENT OUTPATIENT PROGRAM FOR THOSE SUFFERING FROM ADDICTION. WORKED WITH CROSSROADS COUNSELING TO DETERMINE FEASIBILITY OF OFFERING COUNSELING IN OUR SERVICE AREA FOR THOSE WITH SUBSTANCE ABUSE. PROVIDED AN ADDICTIONS CLINIC.PROVIDED SPACE FOR ALCOHOLIC ANONYMOUS TO MEET AT THE HOSPITAL. DEVELOPED REFERRAL BROCHURE INCLUDING MENTAL HEALTH RESOURCES IN SERVICE AREA WHICH CAN BE PROVIDED TO PATIENTS AND FAMILY MEMBERS. ADDITIONALLY, REFERRED TO CROSSROADS COUNSELING WHEN A DRUG OR MENTAL HEALTH ISSUE AROSE IN ER.EDUCATED CLINICAL STAFF AS TO THE ROLE A HOSPITAL'S MEDICAL SOCIAL WORKER CAN PLAY IN ASSISTING WITH APPROPRIATE REFERRALS FOR COUNSELING AND IN ASSISTING IN PSYCHIATRIC PLACEMENTS WHEN WARRANTED. ACCESS TO HEALTH CARE: CONTINUED TO NETWORK WITH OTHER COMMUNITY ORGANIZATIONS REGARDING THE NEED AND OPTIONS FOR TRANSPORTATION. WORKED WITH OHIO HILLS HEALTH SERVICES FINANCIAL COUNSELORS TO PROVIDE EDUCATION AND ASSISTANCE REGARDING ACCESSING AND OPTIONS REGARDING INSURANCE THROUGH THE AFFORDABLE CARE ACT. PROMOTED THE AVAILABILITY OF BARNESVILLE HOSPITAL'S FINANCIAL COUNSELOR WHO CAN REFER PATIENTS TO APPROPRIATE RESOURCES TO ASSIST WITH MEDICAL BILLS AND EXPLORE OPTIONS TO ASSIST PATIENTS WITH OUTSTANDING MEDICAL BILLS. CONTINUED TO RECRUIT AND PROVIDE PRIMARY CARE AND SPECIALTY PHYSICIANS TO MEET THE NEEDS OF THOSE RESIDENTS IN SERVICE AREAS.CONTINUED TO EXPLORE ADDITIONAL TELE-MEDICINE AS AN OPTION TO HAVE SPECIALIST READILY AVAILABLE TO SERVE OUR RURAL REGION.EXPLORED FEASIBILITY OF URGENT CARE TO MEET THE NEEDS OF AREA RESIDENTS AND SPECIFICALLY THE TRANSIENT WORKERS ASSOCIATED WITH OIL AND GAS.EDUCATED COMMUNITY ON SERVICES AVAILABLE AT BARNESVILLE HOSPITAL VIA NEW BROCHURES AND ACTIVE PROMOTION FROM OUR CLINICAL LEADERSHIP. BARNESVILLE HOSPITAL ASSOCIATION PART V, SECTION B, LINE 13B: EVERY SELF PAY PATIENT RECEIVES 20% OFF THEIR INVOICE WHETHER THEY ARE ELIGIBLE FOR THE FINANCIAL ASSISTANCE OR NOT. BARNESVILLE HOSPITAL ASSOCIATION PART V, SECTION B, LINE 15E: PATIENTS CAN FILL OUT THE FORM PROVIDED IN THE REGISTRATION PACKET, ONLINE, OR CALL THE FINANCIAL COUNSELOR FOR ASSISTANCE. BARNESVILLE HOSPITAL ASSOCIATION PART V, SECTION B, LINE 16J: FINANCIAL COUNSELOR PERSONALLY CALLS SELF PAY PATIENTS AND OFFERS THEM AN APPLICATION TO APPLY FOR FAP. BARNESVILLE HOSPITAL ASSOCIATION PART V, SECTION B, LINE 24: THE GROSS CHARGES FOR ANY INDIVIDUAL SERVICE ARE ALL THE SAME. SELF PAY PATIENTS RECEIVE A 20% DISCOUNT AND PATIENTS WITH ANY TYPE OF INSURANCE ARE GIVEN THE DISCOUNT NEGOTIATED IN THE CONTRACT. MEDICARE AND MEDICAID RECEIVE THE MEDICARE AND MEDICAID CONTRACTUALS. BARNESVILLE HOSPITAL ASSOCIATION, INC.: SCHEDULE H, PART V, LINE 7A, URL FOR CHNA:HTTP://WWW.BARNESVILLEHOSPITAL.COM/WP-CONTENT/UPLOADS/2016/12/CHNA16_REVISED1.PDF BARNESVILLE HOSPITAL ASSOCIATION, INC.: SCHEDULE H, PART V, LINE 10A, URL FOR IMPLEMENTATION STRATEGY:HTTP://WWW.BARNESVILLEHOSPITAL.COM/WP-CONTENT/UPLOADS/2016/12/CHNA16_REVISED1.PDF PART I, LINE 3C: IN ADDITION TO FPG, THE ORGANIZATION USES THE FOLLOWING CRITERIA TO DETERMINE ELIGIBILITY: MEDICAL INDIGENCY, INSURANCE STATUS, UNDERINSURANCE STATUS, AND RESIDENCY. ADDITIONALLY, EVERY SELF PAY PATIENT RECEIVES 20% OFF THEIR INVOICE WHETHER THEY ARE ELIGIBLE FOR THE FINANCIAL ASSISTANCE OR NOT. PART I, LINE 7: BARNESVILLE HOSPITAL ASSOCIATION CALCULATED THE COST OF FINANCIAL ASSISTANCE AND MEANS-TESTED GOVERNMENT PROGRAMS USING THE COST-TO-CHARGE RATIO DERIVED FROM SCHEDULE H, WORKSHEET 2, RATIO OF PATIENT CARE COST-TO CHARGES. PART I, LINE 7G: BARNESVILLE HOSPITAL ASSOCIATION INCLUDED COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC (BELMONT PROFESSIONAL ASSOCIATES) AS SUBSIDIZED HEALTH SERVICES ON LINE 7G. FOR 2018, THE AMOUNT WAS $1,038,095. PART I, LN 7 COL(F): THE HOSPITAL HAS A DETAILED FINANCIAL ASSISTANCE POLICY WHICH STATES THAT TO PARTICIPATE IN CHARITY CARE CANDIDATES MUST COOPERATE FULLY. IN ADDITION THE HOSPITAL EDUCATES PATIENTS WITH LIMITED ABILITY TO PAY REGARDING FINANCIAL ASSISTANCE. FOR THIS REASON THE ORGANIZATION BELIEVESTHAT IT ACCURATELY CAPTURES ALL CHARITY CARE DEDUCTIONS PROVIDED ACCORDING TO THE FINANCIAL ASSISTANCE POLICY AND THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS NEGLIGIBLE. PART III, LINE 2: THE ORGANIZATION PROVIDES CARE WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY. BECAUSE THE ORGANIZATION DOES NOT COLLECT AMOUNTS DEEMED TO BE CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE.OF THE ORGANIZATION'S TOTAL REPORTED EXPENSES (APPROXIMATELY $22,080,000 AND $22,412,000 DURING 2018 AND 2017 RESPECTIVELY), AN ESTIMATED $222,000 AND $115,000 AROSE FROM PROVIDING SERVICES TO CHARITY PATIENTS. THE ESTIMATED COSTS OF PROVIDING CHARITY SERVICES ARE BASED ON A CALCULATION WHICH APPLIES A RATIO OF COSTS TO CHARGES TO THE GROSS UNCOMPENSATED CHARGES ASSOCIATED WITH PROVIDING CARE TO CHARITY PATIENTS. THE RATIO OF COST TO CHARGES IS CALCULATED BASED ON THE ORGANIZATION'S TOTAL EXPENSES DIVIDED BY GROSS PATIENT SERVICE REVENUE. THE ORGANIZATION PARTICIPATES IN THE HOSPITAL CARE ASSURANCE PROGRAM (HCAP) WHICH PROVIDES FOR ADDITIONAL PAYMENTS TO HOSPITALS THAT PROVIDE A DISPROPORTIONATE SHARE OF UNCOMPENSATED SERVICES TO THE INDIGENT AND UNINSURED. HCAP REVENUE IS RECORDED IN NET PATIENT SERVICE REVENUE ON THE CONSOLIDATED STATEMENTS OF OPERATIONS AND CHANGES IN NET ASSETS. NET AMOUNTS RECEIVED THROUGH THIS PROGRAM TOTALED APPROXIMATELY $764,000 AND $896,000 FOR 2018 AND 2017, RESPECTIVELY.THE HOSPITAL HAS A DETAILED FINANCIAL ASSISTANCE POLICY WHICH STATES THAT TO PARTICIPATE IN CHARITY CARE CANDIDATES MUST COOPERATE FULLY. IN ADDITION THE HOSPITAL EDUCATES PATIENTS WILL LIMITED ABILITY TO PAY REGARDING FINANCIAL ASSISTANCE. FOR THIS REASON THE ORGANIZATION BELIEVES THAT IT ACCURATELY CAPTURES ALL CHARITY CARE DEDUCTIONS PROVIDED ACCORDING TO THE FINANCIAL ASSISTANCE POLICY AND THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS NEGLIGIBLE. PART III, LINE 3: BARNESVILLE HOSPITAL ASSOCIATION DOES NOT ATTRIBUTE ANY BAD DEBT EXPENSE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY (FAP), THEREFORE NO PORTION OF BAD DEBT ATTRIBUTABLE TO FAP-ELIGIBLE INDIVIDUALS IS CONSIDERED A COMMUNITY BENEFIT. PART III, LINE 4: ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED ON THE ORGANIZATION'S EVALUATION OF ITS MAJOR PAYOR SOURCES OF REVENUE, THE AGING OF THE ACCOUNTS, HISTORICAL LOSSES, CURRENT ECONOMIC CONDITIONS, AND OTHER FACTORS UNIQUE TO THEIR SERVICE AREA AND THE HEALTHCARE INDUSTRY. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. 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, IF NECESSARY (FOR EXAMPLE, 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 DIFFICULTY THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PAYMENTS, 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 HOSPITAL'S ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR SELF-PAY PATIENTS INCREASED FROM 78 PERCENT OF SELF-PAY ACCOUNTS RECEIVABLE AT DECEMBER 31, 2017, TO 80 PERCENT OF SELF-PAY ACCOUNTS RECEIVABLE AT DECEMBER 31, 2018. IN ADDITION, THE HOSPITAL'S BAD DEBT WRITE-OFFS DECREASED APPROXIMATELY $181,000 FROM $547,000 FOR FISCAL YEAR 2017 TO $367,000 FOR FISCAL YEAR 2018. THE HOSPITAL HAS NOT CHANGED ITS CHARITY CARE OR UNINSURED DISCOUNT POLICIES DURING FISCAL YEARS 2017 OR 2018. THE HOSPITAL DOES NOT MAINTAIN A MATERIAL ALLOWANCE FOR DOUBTFUL ACCOUNTS FROM THIRD-PARTY PAYORS, NOR DID IT HAVE SIGNIFICANT WRITE-OFFS FROM THIRD-PARTY PAYORS.THE ALLOWANCE FOR DOUBTFUL ACCOUNTS OF APPROXIMATELY $2,015,000 AND $771,000 AT DECEMBER 31, 2018 AND 2017, RESPECTIVELY, WERE PRIMARILY RESERVED FOR SELF-PAY BALANCES. THE INCREASE IN THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IS PRIMARILY DUE TO AN INCREASE IN THE SELF-PAY ACCOUNTS RECEIVABLE BALANCE. PART III, LINE 8: SURPLUS/ (SHORTFALL): THE COST WAS DETERMINED BY COST TO CHARGE RATIO ON THE COST REPORT. THIS IS AN AGING COMMUNITY AND THEY DESERVE THE BEST CARE AVAILABLE EVEN THOUGH WE HAVE TO SUPPLEMENT THE COST.THE SOURCE USED TO DETERMINE THE AMOUNT OF MEDICARE ALLOWABLE COSTS REPORTED FOR PART III, SECTION B, MEDICARE HAS BEEN PROVIDED FROM THE YEAR ENDED DECEMBER 31, 2018 HOSPITAL STATEMENT OF REIMBURSABLE COST. PART III, LINE 9B: EVERY SELF PAY PATIENT RECEIVES A FINANCIAL AID PACKET WITH PAYMENT OPTIONS AND AN APPLICATION FOR FINANCIAL ASSISTANCE. AS A FOLLOW-UP THE FINANCIAL COUNSELOR PERSONALLY CONTACTS ANY SELF-PAY PATIENT PRESENTING DURING THE WEEK DAYS. PATIENTS ARE BILLED MONTHLY FOR BALANCES NOT COVERED BY INSURANCE, ELIGIBLE FOR FREE CARE OR ELIGIBLE FOR CHARITY DISCOUNTS. AFTER THREE MONTHLY STATEMENTS, IF NO PAYMENTS ARE RECEIVED OR THE PATIENT HAS NOT CONTACTED THE FINANCIAL COUNSELOR, A FINAL NOTICE IS SENT SAYING THEY ARE BEING SENT TO A SECONDARY BILLING COMPANY. THEY WILL TRY TO COLLECT FOR ANOTHER 90 DAYS. PART VI, LINE 2: WE GO INTO THE COMMUNITY AND PERFORM SURVEYS FOR NEEDS ASSESSMENT. WE ALSO GET INPUT FROM AREA PHYSICIANS, PATIENTS, STAFF AND OTHER BUSINESS FACILITIES. PART VI, LINE 3: THE PATIENT FINANCIAL COUNSELOR MEETS WITH ANYONE THAT PRESENTS IF THEY DO NOT HAVE INSURANCE. WE ALSO HAVE IT ON OUR WEBSITE AND POSTED IN THE HOSPITAL. OUR STAFF GOES INTO THE COMMUNITY AND SPEAKS TO DIFFERENT ORGANIZATIONS ABOUT OUR CHARITY AND FREE CARE POLICIES; TELLING THEM WHAT IS AVAILABLE. A FINANCIAL FORM IS GIVEN TO EACH SELF PAY PATIENT THAT REGISTERS AND THE FINANCIAL COUNSELOR'S TELEPHONE NUMBER IS ON ALL INVOICES TO THE PATIENTS. PART VI, LINE 4: BARNESVILLE HOSPITAL IS LOCATED IN AN ECONOMICALLY DEPRESSED APPALACHIAN AREA IN SOUTHEASTERN OHIO. WE SERVE SEVERAL COUNTIES AND THE COUNTY TO THE SOUTH OF US HAS NO HOSPITAL. IT IS AN AGING COMMUNITY WITH A LOT OF RESIDENTS UNDER THE FEDERAL POVERTY LEVEL. WE HAVE LITTLE INDUSTRY WITH THE HOSPITAL BEING THE LARGEST EMPLOYER IN THE COMMUNITY AND THE SCHOOLS ARE SECOND LARGEST. PART VI, LINE 5: OUR BOARD CONSISTS OF COMMUNITY MEMBERS AND THE MAJORITY OF OUR MEDICAL STAFF ARE FROM THE COMMUNITY. IT IS VERY IMPORTANT TO BARNESVILLE HOSPITAL TO PROMOTE THE HEALTH OF THE COMMUNITY BY ORGANIZING COMMUNITY HEALTH SCREENINGS AND EDUCATION FOR OUR COMMUNITY. WE HAVE AN AGING COMMUNITY AND EVERY EFFORT IS MADE TO ASSIST THEM WITH THEIR HEALTHCARE NEEDS. 0 BELMONT PROFESSIONAL ASSOCIATES 639 WEST MAIN STREET BARNESVILLE OH 43713 311352493 501C3 1038095 DEBT FORGIVENESS 1 X X X 0 0 0 0 0 0 0 0 0 DAVID HILLIARD DO BOARD MEMBER 132440 0 0 0 0 0 1618 0 24176 0 158234 0 0 0 DR SHAUN ROE BOARD MEMBER-TERM BEGAN SEP'18 0 196676 0 78070 0 0 0 3339 0 38707 0 316792 0 0 P K SOURI MD BOARD MEMBER 0 220014 0 0 0 0 0 0 0 18632 0 238646 0 0 DAVID PHILLIPS CEO 146727 0 0 0 0 0 1818 0 33741 0 182286 0 0 0 CYNTHIA TOUVELLE CNO 118749 0 0 0 0 0 1384 0 33742 0 153875 0 0 0 JOSEPH A JEFFRIES PHARMACIST 126974 0 0 0 0 0 1461 0 21628 0 150063 0 0 0 MARY B MAZOCH PHARMACIST 156369 0 0 0 0 0 1796 0 26112 0 184277 0 0 0 FORM 990, PART VI, SECTION B, LINE 11B AFTER THE INITIAL REVIEW IT IS REVIEWED BY THE FINANCE COMMITTEE OF THE BARNESVILLE HOSPITAL BOARD OF TRUSTEES FOR REVIEW AND COMMENT. THEN IT IS APPROVED BY THE HOSPITAL BOARD. FORM 990, PART VI, SECTION B, LINE 12C THE WRITTEN CONFLICT OF INTEREST POLICY IS REGULARLY AND CONSISTENTLY MONITORED AND COMPLIANCE ENFORCED BY THE CORPORATE COMPLIANCE OFFICER WHO REPORTS TO THE BOARD. THE SCOPE OF THIS POLICY INCLUDES ALL EMPLOYEES PLUS CONTRACTED EMPLOYEES AND BOARD MEMBERS. THE POLICY IS IN PLACE TO DEFINE SITUATIONS THAT MIGHT OCCUR AND COULD RESULT IN A CONFLICT OF INTEREST BETWEEN AN EMPLOYEE OR BOARD MEMBER AND THE HOSPITAL. THE COVERED PERSONS ARE TO REFRAIN FROM SOLICITING HOSPITAL PATIENTS, PHYSICIANS, STAFF, ETC.; OR ANYTHING THAT COULD RESULT IN A PERSONAL GAIN FOR THE EMPLOYEE OR BOARD MEMBER OR THEIR IMMEDIATE FAMILIES. A SELF DISCLOSURE FROM COVERED PERSONS TO THE CORPORATE COMPLIANCE OFFICER IS REQUIRED ON ANY POTENTIAL CONFLICTS OF INTEREST. THE COVERED PERSONS ARE TO RECUSE THEMSELVES FROM PARTICIPATING IN ANY DELIBERATION OR DECISIONS ON SUCH TRANSACTIONS. THE CORPORATE COMPLIANCE OFFICER WILL REVIEW/RESEARCH THE CONFLICTS DISCLOSED. FORM 990, PART VI, SECTION B, LINE 15 BARNESVILLE HOSPITAL BOARD OF DIRECTORS HAS A COMPENSATION COMMITTEE THAT SETS THE COMPENSATION FOR THE CEO AND REVIEWS ALL PAY CHANGES FOR ANY OTHER EMPLOYEES WHETHER IT IS A SEPARATE INCREASE OR AN ALL EMPLOYEE INCREASE. THE BOARD USES A MANUAL PUBLISHED BY AN INDEPENDENT THIRD-PARTY AS A SOURCE TO DETERMINE REASONABLE COMPENSATION AMOUNTS FOR THE EXECUTIVE COMMITTEE AND ALL OTHER EMPLOYEES. PAY CHANGES ARE APPROVED OR REJECTED BY THE FULL BOARD AND IS DOCUMENTED IN THE BOARD OF DIRECTOR MINUTES. FORM 990, PART VI, SECTION C, LINE 19 THE 990 IS THE ONLY DOCUMENT MADE AVAILABLE TO THE PUBLIC. IF ANYONE WANTS TO REVIEW THE 990 THEY MAY CONTACT THE ADMINISTRATIVE OFFICE IN PERSON, BY TELEPHONE OR MAIL. WE WILL MAKE THE DOCUMENTS AVAILABLE AT THAT TIME. IF THE PERSON PRESENTS IN PERSON WE WILL TRY TO ACCOMODATE THEM THAT DAY. FORM 990, PART IX, LINE 11G OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,280,058. MANAGEMENT AND GENERAL EXPENSES 153,619. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,433,677. SERVICE CONTRACTS: PROGRAM SERVICE EXPENSES 920,379. MANAGEMENT AND GENERAL EXPENSES 110,454. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,030,833. FORM 990, PART XI, LINE 9: PENSION RELATED CHANGES 165,105. FORM 990 PART XII, LINE 2C THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. BELMONT PROFESSIONAL ASSOCIATES INC 639 W MAIN ST BARNESVILLE OH 43713 311352493 PHYSICIAN PRACTICE OH 501(C)(3) LINE 3 BARNESVILLE HOSPITAL 1 BARNESVILLE HOSPITAL FOUNDATION 639 W MAIN ST BARNESVILLE OH 43713 113804786 SUPPORT FOR HOSPITAL OH 501(C)(3) LINE 12A, I N/A 0 BELMONT CO HEALTH SERVICES INC 639 W MAIN ST BARNESVILLE OH 43713 341566526 RETAIL PHARMACY OH BARNESVILLE HOSPITAL C 518104 1553093 1.00000 1 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 BARNESVILLE HOSPITAL FOUNDATION C 422678 CASH VALUE BARNESVILLE HOSPITAL FOUNDATION P 70458 CASH VALUE BELMONT PROFESSIONAL ASSOCIATES B 1038095 CASH VALUE