2019-05-15T09:34:56-05:00 2018-06-30 390758449 WIPLFLI LLP 4890 OWEN AYRES COURT SUITE 200 EAU CLAIRE WI 54701 990 2017-07-01 390831153 CUMBERLAND MEMORIAL HOSPITAL D/B/A CUMBERLAND HEALTHCARE CUMB 7158222741 1110 7TH AVENUE CUMBERLAND WI 54829 MICHAEL GUTSCH CEO 7158222741 2019-05-14 1 HOLLY POKRANDT CPA P00449155 7158323407 2019-05-14 137.26.200.211 2019-05-14 09:54:30 CD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 2F3CDBAF1037015F68690DD19EBC2430D808C728 2017 2019-02-21 02:37:17Z MICHAEL GUTSCH 1110 7TH AVENUE CUMBERLAND WI 54829 26745137 0 X WWW.CUMBERLANDHEALTHCARE.COM X 1955 WI AN INDEPENDANT, COMMUNITY-BASED HEALTH SYSTEM DEDICATED TO PROVIDING EXCEPTIONAL QUALITY CARE, EVERY STEP OF THE WAY. 7 3 304 101 51404 -5124 90622 91730 27399247 26555380 104415 72996 14680 16951 27608964 26737057 0 0 0 0 14790720 14296683 0 0 0 12123418 11330192 26914138 25626875 694826 1110182 20746801 21675038 7018943 6842473 13727858 14832565 X TO BE AN INDEPENDENT, COMMUNITY-BASED HEALTH SYSTEM DEDICATED TO PROVIDING EXCEPTIONAL QUALITY CARE, EVERY STEP OF THE WAY. 0 0 22713120 26215601 CUMBERLAND MEMORIAL HOSPITAL D/B/A CUMBERLAND HEALTHCARE (THE ORGANIZATION") IS AN INDEPENDENT, NONPROFIT, COMMUNITY-BASED RESIDENTIAL FACILITY THAT SERVES NORTHWEST WISCONSIN. THE ORGANIZATION OPERATES A HOSPITAL (CUMBERLAND MEMORIAL HOSPITAL) AND TWO CLINICS (LOCATED IN CUMBERLAND AND TURTLE LAKE). CUMBERLAND MEMORIAL HOSPITAL BECAME A CRITICAL ACCESS HOSPITAL ON AUGUST 19, 2005, LICENSED FOR 25 ACUTE CARE BEDS, INCLUDING 3 IN THE BIRTHPLACE. SERVICES INCLUDE, BUT ARE NOT LIMITED TO, THERAPY, WOUND CARE, CHEMOTHERAPY, OBSTETRICS, AND GENERAL SURGERY. DURING FISCAL YEAR 2018, ACUTE CARE DAYS TOTALED 1,430, SWING BED DAYS TOTALED 1,796, AND NEWBORN DAYS TOTALED 112. THE ORGANIZATION PROVIDED 35 INPATIENT AND 355 OUTPATIENT SURGERIES ALONG WITH 239 SCOPE PROCEDURES. THERE WERE ALSO 2,947 EMERGENCY ROOM VISITS. CUMBERLAND CLINIC TOTAL VISITS WERE 21,553 AND TURTLE LAKE WERE 2,800. 22713120 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 38 0 304 1 1 1 0 0 0 0 0 0 0 0 0 X 7 3 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X ANGIE MARTENS 7158222741 1110 7TH AVENUE CUMBERLAND WI 54829 MATT GORES CHAIRPERSON BEGINNING 5-16-18 1.00 X 2775 0 0 JOSEPH LESCHISIN TRUSTEE 1.00 X 2400 0 0 CHARLES CHRISTENSEN CHAIRPERSON UNTIL 5-15-18 1.00 X X 1750 0 0 CANDACE COTONE VICE CHAIR 1.00 X X 2400 0 0 MARTIN PETERS TREASURER 1.00 X X 2000 0 0 ANN HENDRICKS SECRETARY 1.00 X X 2700 0 0 BARB ANKARLO TRUSTEE 1.00 X 1600 0 0 MICHAEL GUTSCH CEO 40.00 X 240761 0 38827 ANGIE MARTENS CFO 40.00 X 134629 0 7440 BENJAMIN BRENNA DIRECTOR OF REHAB 40.00 X 127154 0 43913 DONALD FULLERTON CRNA 20.00 X 203515 0 45991 JEFFREY KUEHN CRNA 20.00 X 191586 0 25030 ROBERT LINDBERG COO 40.00 X 135298 0 30876 GARY DEGERMAN PHYSICIAN 40.00 X 217256 0 38122 1265824 0 230199 13 0 1 0 CUMBERLAND CLINIC 1110 7TH AVENUE CUMBERLAND WI 54829 ER PHYSICIAN COVERAGE 2171331 SHARED MED TECH 202 W NEWTON ST RICE LAKE WI 54868 US, NUC MED, MRI 478149 MEDICAL SOLUTIONS 1010N 102ND ST SUITE 300 OMAHA NE 68114 POOL STAFF 116926 3 9320 2270 80140 91730 HOSPITAL REVENUE 621990 26216316 26215601 715 OTHER OPERATING REVENUE 621990 339064 50689 288375 26555380 72996 72996 25031 9320 8080 16951 16951 26737057 26215601 51404 378322 X 483572 483572 10131568 9408274 723294 254542 238234 16308 2658404 2394016 264388 768597 684081 84516 27867 27867 69860 69860 5008224 4884421 123803 137348 137348 309737 32352 277385 245844 245844 423972 356565 67407 76489 61521 14968 1165291 980023 185268 118666 118666 BILLABLE MEDICAL SUPPLI 2157672 2157672 PROVISION FOR BAD DEBTS 939877 939877 REPAIRS & MAINTENACE 255635 250104 5531 EQUIPMENT RENT & LEASES 149293 149293 244417 176687 67730 25626875 22713120 2913755 0 513312 1118393 2529043 2784979 3485989 3649838 98436 88693 490536 462046 86867 51346 26702915 16866171 9623185 9836744 1639502 3582999 869989 1409942 100000 20746801 21675038 2189565 2182131 0 17500 2182941 1916120 2215385 2034990 431052 691732 7018943 6842473 X 13727858 14832565 13727858 14832565 20746801 21675038 1110182 -5475 0 X X 0 1 X 0 0 X 0 0 0 0 0 0 0 0 1 4438 4438 0 PART II-B, LINE 1: CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. (THE ORGANIZATION") 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. A PORTION OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTH CARE ENVIRONMENT. THE ORGANIZATION IS ALSO A MEMBER OF THE RURAL WISCONSIN HEALTH COOPERATIVE (RWHC). EACH YEAR, THE ORGANIZATION PAYS MEMBERSHIP FEES TO THE RWHC. RWHC PROVIDES SUPPORT SERVICES FOR A NUMBER OF ITS MEMBER HOSPITALS THROUGHOUT THE STATE OF WISCONSIN. SOME OF THE MANY SERVICES PROVIDED TO MEMBER HOSPITALS INCLUDE PROVIDING ASSISTANCE TO ORGANIZATIONS IN FINDING GRANT FUNDING FOR NEW PROGRAMS, LEGAL SERVICES, REIMBURSEMENT REVIEW SERVICES, ACCOUNTING ASSISTANCE, CONTRACTING FOR THERAPIST AND EMERGENCY ROOM PATIENT CARE COVERAGE, AND ADMINISTRATIVE CONSULTING SERVICES. AS A PART OF THESE SERVICES, THE RWHC ALSO DOES PROVIDE ANALYSIS ON CURRENT HEALTH CARE ISSUES IN AN EFFORT TO PROMOTE AND BETTER HEALTH CARE FOR HOSPITALS IN RURAL COMMUNITIES THROUGHOUT WISCONSIN. ONE OF THESE EFFORTS ALSO INCLUDES SOME LOBBYING ON THE PART OF THE MEMBER ORGANIZATIONS. A PORTION OF THE FEES PAID BY THE ORGANIZATION IN FY2017 WERE RELATED TO LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE HEALTH CARE ENVIRONMENT IN THE STATE OF WISCONSIN. 0 956803 956803 13885335 9146753 4738582 1733384 99434 1633950 9817070 7619984 2197086 310323 310323 9836744 CAPITAL LEASE OBLIGATIONS 291732 THIRD-PARTY PAYABLES 400000 691732 25791705 -5475 -5475 25797180 939877 939877 26737057 24686998 0 24686998 939877 939877 25626875 PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS NET AGAINST REVENUE 939,877. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS NET AGAINST REVENUE 939,877. GOLF OUTING 26225 9320 16905 600 2475 2101 450 PROGRESSIVE DINNER 8126 8126 2319 135 34351 9320 25031 600 4794 2101 585 8080 16951 1 1 X 1 X 1 X 1 1 0 1 1 59348 59348 0.00240 2397798 1850421 547377 0.02220 2457146 1850421 606725 0.02460 156108 156108 0.00630 50028 50028 0.00200 1890965 1300786 590179 0.02390 8673 8673 0.00040 2105774 1300786 804988 0.03260 4562920 3151207 1411713 0.05720 1085 1085 0.00000 1085 1085 0.00000 0 480039 96008 11313489 11524839 -211350 X 1 1 1 1 CUMBERLAND MEMORIAL HOSPITAL 1110 7TH AVENUE CUMBERLAND WI 54829 SEE SCHEDULE H PART V SUPPLEMENTAL 1058 X X X X AMBULANCE SERVICE; RURAL HEALTH CLINICS CUMBERLAND MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 15 1 1 1 1 X SEE SCHEDULE H PART V SUPPLEMENTAL X X 1 15 1 SEE SCHEDULE H PART V SUPPLEMENTAL 0 1 X 25.000000000000 300.000000000000 X X X X 1 1 X X X X 1 X SEE SCHEDULE H PART V SUPPLEMENTAL X SEE SCHEDULE H PART V SUPPLEMENTAL X SCH H PART V SUPPLEMENTAL X X X X X X 1 X 0 X X X 1 X 0 0 CUMBERLAND MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: IN MAY 2016, THE CHNA WAS COMPLETED THROUGH THRIVE BARRON COUNTY, WHICH BRINGS ALL LOCAL COMPLETING HEALTHCARE SYSTEMS TOGETHER AND THE BARRON COUNTY DEPARTMENT OF HEALTH & HUMAN SERVICES. OVER 900 SURVEYS WERE SENT OUT ELECTRONICALLY AND IN-PERSON TO BARRON COUNTY RESIDENTS ASKING THEM ABOUT WHAT THEY THOUGHT OUR TOP HEALTH CONCERNS WERE. ONCE THE VOTES WERE TALLIED, THE THRIVE BARRON COUNTY STEERING COMMITTEE MET TO DETERMINE THE HEALTH CONCERNS MOVING FORWARD. CUMBERLAND MEMORIAL HOSPITAL PART V, SECTION B, LINE 6A: CUMBERLAND MEMORIAL HOSPITAL WORKED WITH LAKEVIEW MEDICAL CENTER/MARSHFIELD CLINIC (RICE LAKE, WI) AND MAYO CLINIC HEALTH SYSTEM - NORTHLAND (BARRON, WI) TO IDENTIFY AND PRIORITIZE HEALTH NEEDS. IN MAY 2016, WE HAD INPUT FROM THRIVE BARRON COUNTY, WHICH INCLUDES CUMBERLAND HEALTHCARE, LAKEVIEW MEDICAL CENTER, MARSHFILED CLINIC AND MAYO CLINIC HEALTH SYSTEM, AND THE BARRON COUNTY DEPARTMENT OF HEALTH & HUMAN SERVICES. CUMBERLAND MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: CUMBERLAND MEMORIAL HOSPITAL WORKED WITH BARRON COUNTY PUBLIC HEALTH (BARRON, WI) TO IDENTIFY AND PRIORITIZE HEALTH NEEDS. CUMBERLAND MEMORIAL HOSPITAL PART V, SECTION B, LINE 7D: COPIES OF THE COMMUNITY HEALTH NEEDS ASSESSMENT WERE DISTRIBUTED TO THE SENIOR CENTER AND TO THE PUBLIC LIBRARY. CUMBERLAND MEMORIAL HOSPITAL ALSO BRINGS EXTRA COPIES OF THE CHNA TO THE COMMUNITY EVENTS IN WHICH THEY PARTAKE. CUMBERLAND MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: BARRON COUNTY HAS CREATED A GROUP CALLED THRIVE BARRON COUNTY, WHICH IS MADE UP OF THREE HEALTHCARE FACILITIES IN THE COUNTY, INCLUDING CUMBERLAND MEMORIAL HOSPITAL. TOGETHER THRIVE BARRON COUNTY CONDUCTED A CHNA IN 2012 AND 2015. FROM THE 2015 CHNA, THE TOP THREE HEALTH CONCERNS WERE ALCOHOL, TOBACCO, AND OTHER DRUG ABUSE (ATOBDA), MENTAL HEALTH, AND CHRONIC DISEASES. PLANS HAVE BEEN MADE TO OPEN A NEW BEHAVIORAL HEALTH UNIT. CUMBERLAND HEALTHCARE WILL ALSO ASSIST THE COMMUNITY BY GETTING TO THE ROOT OF THE PATIENTS' ISSUES THROUGH PROVIDING COUNSELING SERVICES. IN ADDTION, CUMBERLAND HEALTHCARE PROVIDES "KICKIN' BUTTS" SMOKING CESSATION CLASSES. CUMBERLAND ALSO OFFERS "KNOW YOUR NUMBERS" HEALTH FAIR EVERY MAY WHICH INCLUDES FREE HEALTH SCREENING, COMPLETED THROUGH A SIMPLE BLOOD DRAW, HEALTH INFORMATION, BREAKFAST AND GIVEAWAYS. AS WITH ALL HEALTHCARE ORGANIZATIONS, ADEQUATE RESOURCES ARE NOT AVAILABLE TO ADDRESS EVERY UNMET HEALTH NEED IN THE COMMUNITIES CUMBERLAND MEMORIAL HOSPITAL SERVES. THERE WERE ITEMS IDENTIFIED IN THE CHNA WHICH WERE NOT ADDRESSED, HOWEVER, ALL ITEMS WERE CONSIDERED IF A NEED WAS BROUGHT TO THE ATTENTION OF THE STEERING COMMITTEE DURING THE INFORMATION GATHERING PHASE OF THE CHNA PROCESS. SEVERAL OF THE ITEMS WHICH WERE NOT ADDRESSED PRIMARILY WERE NOT ADDRESSED DUE TO THE FINANCIAL CONSTRAINT OF PROVIDING A NEW SERVICE FOR A LIMITED POPULATION OF PEOPLE. OVER THE NEXT THREE YEARS, CUMBERLAND MEMORIAL HOSPITAL WILL CONTINUE TO PLAY A LEADING ROLE IN ADDRESSING THE HEALTH NEEDS OF THOSE WITHIN THE COMMUNITY, CONGRUENT WITH THE HOSPITAL'S MISSION. CUMBERLAND MEMORIAL HOSPITAL PART V, SECTION B, LINE 16J: THE FINANCIAL ASSISTANCE POLICY IS AVAILABLE THROUGH THE BUSINESS OFFICE STAFF. PATIENTS ARE ENCOURAGED TO CONTACT A FINANCIAL COUNSELOR FOR FURTHER INFORMATION ON THE FINANCIAL ASSISTANCE POLICY. THE HOSPITAL'S WEBSITE ALSO ENCOURAGES PATIENTS TO INQUIRE ABOUT THE FINANCIAL ASSISTANCE POLICY. THE BACK OF PATIENT STATEMENTS ALSO GIVE INFORMATION ON THE FINANCIAL ASSISTANCE POLICY.16I - ENGLISH IS THE ONLY PRIMARY LANGUAGE THEREFORE THE FAP, FAP APPLICATION FORM, AND PLAIN LANGUAGE SUMMARY HAS NOT BEEN TRANSLATED. PART V, LINE 7A: HOSPITAL FACILITIES WEBSITE: CUMBERLANDHEALTHCARE.COM/PATIENTS-VISITORS/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ PART V, LINE 10A: HOSPITAL FACILITY'S MOST RECENTLY ADOPTED IMPLEMENTATION STRATEGY IS POSTED ON THEIR WEBSITE: CUMBERLANDHEALTHCARE.COM/PATIENTS-VISITORS/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ PART V, LINE 16A, B, C: THE FAP WAS WIDELY AVAILABLE ON A WEBSITE: HTTPS://CUMBERLANDHEALTHCARE.COM/PATIENTS-VISITORS/PATIENT-FINANCIAL-SERVICES/THE FAP APPLICATION FORM WAS WIDELY AVAILABLE ON A WEBSITE: HTTPS://CUMBERLANDHEALTHCARE.COM/PATIENTS-VISITORS/PATIENT-FINANCIAL-SERVICES/A PLAIN LANGUAGE SUMMARY OF THE FAP WAS WIDELY AVAILABLE ON A WEBSITE: HTTPS://CUMBERLANDHEALTHCARE.COM/PATIENTS-VISITORS/PATIENT-FINANCIAL-SERVICES/ 2 2 - CUMBERLAND HEALTHCARE MEDICAL CLINIC 1110 7TH AVENUE CUMBERLAND WI 54829 RURAL HEALTH CLINIC 4 - CUMBERLAND HEALTHCARE TURTLE LAKE CENTER 632 US HWY 8 TURTLE LAKE WI 54889 RURAL HEALTH CLINIC PART I, LINE 7: THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST-TO-CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES, EXCLUDING THE PROVISION FOR BAD DEBTS DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST-TO-CHARGE RATIO IS APPLIED AGAINST HOSPITAL REVENUE AND EXPENSE CATEGORIES TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER IRS SUGGESTED COSTING METHODS FOR THE FORM 990. THE COSTING METHODOLOGY USED IS BASED ON MEDICARE COST REPORTING METHODS. PART I, LINE 7G: THE COST OF SUBSIDIZED SERVICES IS BASED ON COST ALLOCATIONS FROM THE MEDICARE COST REPORT. ALLOWABLE COSTS ARE ASSIGNED DIRECTLY TO DEPARTMENTS THROUGHOUT THE YEAR AND THEN THE COST REPORT USES THE ALLOCATION METHODOLOGY TO ASSIGN ALL OTHER COSTS TO CALCULATE SERVICE LINE COSTS. SUBSIDIZED HEALTH SERVICES INCLUDED THE CLINICS AND THE EMERGENCY ROOM DEPARTMENT. THESE SERVICES ARE UNAVAILABLE TO MEMBERS OF THE COMMUNITY OTHER THAN THROUGH CUMBERLAND MEMORIAL HOSPITAL. IT HAS BEEN THE GOAL OF CUMBERLAND MEMORIAL HOSPITAL TO PROVIDE THESE SERVICES TO THE COMMUNITY REGARDLESS OF A PATIENT'S ABILITY TO PAY. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 939,877. PART II, COMMUNITY BUILDING ACTIVITIES: WHILE THERE IS A GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFIT HOSPITAL'S 'COMMUNITY BENEFIT', THIS IS A WORK IN PROGRESS. CUMBERLAND MEMORIAL HOSPITAL PROVIDES SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS AND IN ADDITION, THE HOSPITAL BELIEVES THAT IT PROVIDES A CRITICALLY IMPORTANT COMMUNITY BENEFIT WHICH IS NOT QUANTIFIED. SEE PART 1, LINE 7 FOR THE CALCULATED COST OF PROVIDING COMMUNITY SERVICES. CUMBERLAND MEMORIAL HOSPITAL, LIKE MOST RURAL HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY WHICH WITHOUT THE HOSPITAL WOULD NOT BE AVAILABLE LOCALLY. BEYOND INPATIENT HOSPITALIZATIONS, THE HOSPITAL PROVIDES LOCAL ACCESS TO MANY HEALTH SERVICES: AMBULANCE SERVICES, BIRTHING CENTER, DIAGNOSTICS, EMERGENCY SERVICES & URGENT CARE, EXTENDED CARE, INPATIENT CARE, LABORATORY SERVICES, OCCUPATIONAL HEALTH, REHABILITATION SERVICES, SPECIALTY MEDICINE, SLEEP CENTER, SPEECH, AND SURGICAL SERVICES. PART III, LINE 2: THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST-TO-CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES, EXCLUDING THE PROVISION FOR BAD DEBTS, DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST-TO-CHARGE RATIO IS APPLIED AGAINST THE TOTAL CHARGES THAT ARE WRITTEN OFF DURING THE FISCAL YEAR TO ESTIMATE THE COST OF THE CARE OF PATIENTS THAT HAVE ACCOUNTS THAT ARE DEEMED TO BE BAD DEBTS TO THE HOSPITAL. THE HOSPITAL ALSO PROVIDES DISCOUNTS TO ELIGIBLE UNINSURED OR UNDERINSURED PATIENTS UNDER ITS CHARITABLE CARE POLICY. THESE AMOUNTS ARE INCLUDED IN THE CONTRACTUAL ADJUSTMENTS ON THE FINANCIAL STATEMENTS AND ARE NOT INCLUDED IN THE RATIO AS DESCRIBED ABOVE AND APPROVED BY THE IRS FOR USE ON FORM 990. IF CONSIDERED, THESE ADDIITONAL WRITE-OFF AMOUNTS TO UNINSURED OR UNDERINSURED ACCOUNTS WOULD ALSO INCREASE THE ESTIMATED BAD DEBT EXPENSE AMOUNT ASSOCIATED WITH THESE UNCOLLECTIBLE ACCOUNTS TO THE HOSPITAL. PART III, LINE 3: MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER THE HOSPITAL HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO ACCOUNTS RECEIVABLE. MANY TIMES PATIENTS ARE UNABLE TO COMPLETE THE REQUIRED CHARITY CARE APPLICATION AND ARE TRANSFERRED TO COLLECTION SERVICES EVEN THOUGH THE HOSPITAL PROVIDES THIS INFORMATION TO ALL PATIENTS AND ASSISTANCE WITH THE APPLICATIONS. DUE TO NO RESPONSES FROM SOME PATIENTS, A SMALL AMOUNT OF BAD DEBTS COULD BE CONSIDERED AS CHARITY CARE. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE AND CREDIT POLICY: 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 DOUBTFUL 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 DOUBTFUL 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 UNCOLLECTIBLE AMOUNTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET BEEN PAID, OR FOR PAYORS AND PATIENTS 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 DOUBTFUL ACCOUNTS. THE AUDITED FINANCIAL STATEMENTS DO NOT INCLUDE A SEPARATE FOOTNOTE REGARDING BAD DEBT EXPENSE. PART III, LINE 8: CUMBERLAND MEMORIAL HOSPITAL IS DESIGNATED A CRITICAL ACCESS HOSPITAL AND AS SUCH A PORTION OF ITS REVENUE IS PAID UNDER A COST REIMBURSEMENT SYSTEM. BASED ON THE INSTRUCTIONS, THE TOTAL MEDICARE REVENUE SHOWN ON THIS FORM 990 INCLUDES ONLY A PORTION OF THE GROSS MEDICARE REVENUE THAT IS ACTUALLY RECEIVED BY THE HOSPITAL FROM THE MEDICARE PROGRAM. THE AMOUNTS LISTED FOR MEDICARE DO NOT INCLUDE PHYSICIAN AND MID-LEVEL PRACTITIONER SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT CUMBERLAND MEMORIAL HOSPITAL OR AMBULANCE SERVICES. PHYSICIAN COVERAGE IS REIMBURSED PRIMARILY ON A FEE SCHEDULE REIMBURSEMENT METHODOLOGY AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY AND AMBULANCE SERVICES PROVIDED TO MEDICARE PATIENTS ARE VITAL TO THE WELL-BEING OF THE COMMUNITY AND AS SUCH THESE COSTS AND SHORTFALLS SHOULD ALSO BE CONSIDERED AS AN ADDITIONAL BENEFIT THAT CUMBERLAND MEMORIAL HOSPITAL PROVIDES TO THE COMMUNITY AND SURROUNDING AREA OF CUMBERLAND, WISCONSIN. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON AN OVERALL AVERAGE COST TO CHARGE RATIO AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUE (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE) DIVIDED BY TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT EXPENSE. THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES WHICH ARE REIMBURSED ON A COST METHODOLOGY EXCLUDING THE FEE SCHEDULE ITEMS LIKE PHYSICIAN AND MID-LEVEL PRACTITIONER SERVICES WHICH THE HOSPITAL WOULD SHOW A LARGE LOSS ON THESE SERVICES. WHETHER THERE IS A SHORTFALL OR SURPLUS ON SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PEOPLE, WHICH ARE TYPICALLY ELDERLY OR DISABLED MEMBERS OF THE COMMUNITY, ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTH CARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. PART III, LINE 9B: UNDER THE HOSPITAL'S COLLECTION AND CHARITABLE CARE POLICIES, CUMBERLAND MEMORIAL HOSPITAL MAKES EVERY ATTEMPT TO IDENTIFY AND PROMOTE CHARITY CARE TO PATIENTS. INCLUDED IN THE HOSPITAL'S CHARITABLE CARE POLICY IT IS NOTED THAT PATIENTS MAY QUALIFY FOR CHARITY CARE EITHER PRIOR TO ADMISSION OR FOLLOWING DISCHARGE. ALL INPATIENT SELF-PAY ADMISSIONS ARE SCREENED BY THE HOSPITAL'S FINANCIAL COUNSELOR TO ALLOW THESE PATIENTS THE ABILITY TO COMPLETE THEIR APPLICATION DURING THEIR STAY AT THE HOSPITAL, DEPENDING UPON THE PATIENT'S CONDITION, THE PATIENT'S RESPONSIBLE PARTY MAY BE CONTACTED TO COMPELTE AND RETURN THE FORMS AT A LATER TIME WHEN THEIR CARE ALLOWS THIS COMPLETION. DURING THE PATIENT ACCOUNT COLLECTION PROCESS, SELF-PAY PATIENTS ARE ALSO INFORMED OF THE HOSPITAL'S COLLECTION POLICES AS WELL AS THE CHARITY AND COMMUNITY CARE PROGRAM TO ALLOW PATENTS THE OPPORTUNITY TO COMPLETE THE APPROPRIATE FORMS AND QUALIFY UNDER THE PROGRAM. INCLUDED IN THE POLICY, IT IS ALSO NOTED THAT THE HOSPITAL RESERVES THE RIGHT TO MAKE OR GRANT ADDITIONAL CHARITY CARE ON A CASE-BY-CASE BASIS. PART VI, LINE 2: THE HOSPITAL ASSESSES THE NEEDS OF THE COMMUNITY THROUGH SURVEYS AND BY RECOGNIZING WHY CERTAIN PATIENTS ARE REFERRED OUT OF THE AREA. THE HOSPITAL THEN ATTEMPTS TO GET SPECIALISTS IN THE IDENTIFIED AREAS INTO THE HOSPITAL TO SEE PATIENTS AND MEET THEIR NEEDS. IN JULY 2015, WE OPENED AN ONCOLOGY UNIT AFTER RECOGNIZING A NEED AND WANT FOR PATIENTS TO RECEIVE TREATMENT CLOSE TO HOME. WE ALSO RECOGNIZED A GROWING NEED FOR DIABETIC EDUCATION. BECAUSE THE RECOGNIZED NEED FOR MENTAL HEALTH, WE HIRED A MENTAL HEALTH COUNSELOR AT THE END OF FY16. SMOKING CESSATION CLASSES HAVE ALSO BEEN HELD THROUGHOUT THE YEAR. A PATIENT ADVISORY COUNCIL WAS ALSO FORMED AT THE END OF FY16. ACTION WILL TAKE PLACE AS A RESULT OF THE COUNCIL'S RECOMMENDATIONS. IN FY 2017 DIABETIC EDUCATION CLASSES HAVE BEEN ADDED. LOOKING TO ADD ENT SPECIALIST SO WE CAN SERVE THAT NEED AND PATIENTS DON'T HAVE TO TRAVEL OUT OF THE AREA. WE LOOK FOR OPPORTUNITIES TO WORK WITH THE SCHOOL AND SERVE THE NEEDS TO STUDENTS AND BRING SERVICES TO THEM RATHER THAN THEIR PARENTS HAVING TO LEAVE THEIR JOBS TO BRING STUDENTS TO APPOINTMENTS AT OUR FACILITY. PART VI, LINE 3: IF A PATIENT IS IDENTIFIED AS UNINSURED, HOSPITAL STAFF WORKS WITH THE PATIENT OR THEIR FAMILY TO DETERMINE IF THEY ARE ELIGIBLE FOR ANY TYPE OF GOVERNMENT PROGRAMS OR QUALIFY FOR THE HOSPITAL'S CHARITY CARE PROGRAM. ASSISTANCE IS ALSO PUBLICIZED ON OUR WEBSITE. PART VI, LINE 4: THE HOSPITAL SERVES THE COMMUNITIES OF CUMBERLAND, TURTLE LAKE, AND ALMENA, WI AND SURROUNDING COMMUNITIES WITHIN A 20 MILE RADIUS. THERE ARE THREE OTHER HOSPITALS LOCATED IN THE RURAL AREA THAT THE ORGANIZATION SERVES. PART VI, LINE 5: A MAJORITY OF OUR ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA. OUR ORGANIZATION EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY FOR SOME OR ALL OF ITS DEPARTMENTS. WE ALSO PARTICIPATE IN COMMUNITY HEALTH FAIRS AND PROVIDE SERVICE AT SPORTING EVENTS. SURPLUS FUNDS ARE INVESTED BACK INTO THE FACILITY AND ITS EQUIPMENT TO ENSURE THE NEEDED SERVICES ARE CONTINUED TO BE PROVIDED IN THIS COMMUNITY. PART VI, LINE 7, REPORTS FILED WITH STATES WI X X X 0 0 0 0 0 0 0 0 0 MICHAEL GUTSCH CEO 212836 0 27925 0 0 0 7335 0 31492 0 279588 0 0 0 BENJAMIN BRENNA DIRECTOR OF REHAB 119595 0 2795 0 4764 0 4107 0 39806 0 171067 0 0 0 DONALD FULLERTON CRNA 203515 0 0 0 0 0 6421 0 39570 0 249506 0 0 0 JEFFREY KUEHN CRNA 191586 0 0 0 0 0 7851 0 17179 0 216616 0 0 0 ROBERT LINDBERG COO 129175 0 6123 0 0 0 0 0 30876 0 166174 0 0 0 GARY DEGERMAN PHYSICIAN 217256 0 0 0 0 0 6630 0 31492 0 255378 0 0 0 A WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 2014-10-28 2925000 REFUND PRIOR ISSUE 0 0 0 A 925000 2925000 58500 352739 2513761 2009 0 1 1 1 A 0 0 0 0 0 0 1 A 0 1 0 0 0 0 0 0 0 A 0 LAURI RANALLO FAMILY MEMBER OF CHARLES CHRISTENSEN, CHAIRPERSON UNTIL 5-15-18 47027 EMPLOYMENT COMPENSATION 0 FORM 990, PART VI, SECTION B, LINE 11B THE RETURN IS REVIEWED BY THE CHIEF FINANCIAL OFFICER AND A FINAL DRAFT IS GIVEN TO THE BOARD MEMBERS OF CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. UPON APPROVAL FROM THE BOARD MEMBERS, THE RETURN IS FILED WITH THE INTERNAL REVENUE SERVICE (IRS). FORM 990, PART VI, SECTION B, LINE 12C CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. REQUIRES ITS BOARD MEMBERS TO SIGN A CONFLICT OF INTEREST STATEMENT ANNUALLY. OFFICERS AND KEY EMPLOYEES OF CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. SIGN A CODE OF CONDUCT STATEMENT. IN THE CODE OF CONDUCT STATEMENT IT MENTIONS THE CONFLICT OF INTEREST. ANY PERSON THAT BELIEVES TO HAVE A CONFLICT SHOULD DISCLOSE AS A MATTER OF RECORD TO THE BOARD ON AN ANNUAL BASIS OR AS THE INTEREST DEVELOPS AND BEFORE IT IS CONSUMMATED. ANY DIRECTOR HAVING A CONFLICT MAY NOT VOTE OR USE PERSONAL INFLUENCE ON THE MATTER. THE DIRECTOR CAN STATE THEIR POSITION ON THE MATTER BEFORE ABSTAINING FROM VOTE. FORM 990, PART VI, SECTION B, LINE 15 EXECUTIVE SALARIES ARE SET ANNUALLY CONSIDERING COMPENSATION LEVELS AT SIMILARLY SITUATED ORGANIZATIONS (TYPICALLY NOT-FOR-PROFIT HEALTH CARE ORGANIZATIONS IN SIMILAR REVENUE CATEGORIES). THE BOARD OF DIRECTORS IS RESPONSIBLE FOR SETTING THE SALARY OF THE CEO AND CFO BASED ON THEIR JOB PERFORMANCE. THE BOARD RELIES UPON COMPARABILITY DATA DEVELOPED BY OUTSIDE CONSULTANTS TO SUPPORT ITS DECISION MAKING PROCESS AND TO ENSURE COMPETITIVE SALARY LEVELS. ALL OTHER NON-UNION WAGES ARE REVIEWED SEMI-ANNUALLY IN COMPARISON TO THE RURAL WISCONSIN HEALTH COOPERATIVE WAGE SURVEY. THIS WAGE SURVEY INCLUDES WAGE DATA OF 27 RURAL HEALTH CARE ORGANIZATIONS. THE GOAL OF THE ORGANIZATION IS TO REMAIN WITHIN THE WAGE SURVEY AVERAGES, BASED ON YEARS OF SERVICE TO BE COMPETITIVE WITH SIMILAR ORGANIZATIONS. FORM 990, PART VI, SECTION C, LINE 19 CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,005,273. MANAGEMENT AND GENERAL EXPENSES 123,803. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,129,076. CONTRACTED NURSING SERVICES: PROGRAM SERVICE EXPENSES 255,148. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 255,148. CONTRACTED RADIOLOGY/NUCLEAR MEDICINE SERVICES: PROGRAM SERVICE EXPENSES 478,083. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 478,083. CONTRACTED PHYSICIANS: PROGRAM SERVICE EXPENSES 1,407,770. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,407,770. CONTRACTED - PHARMACY : PROGRAM SERVICE EXPENSES 949,304. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 949,304. CONTRACTED ER PHYSICIANS: PROGRAM SERVICE EXPENSES 788,843. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 788,843. FORM 990, PART XII, LINE 2C, AUDIT OVERSIGHT: CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT INC.'S ENTIRE BOARD OF DIRECTORS IS RESPONSIBLE FOR THE FINANCIAL STATEMENT AUDIT AND SELECTION OF THE INDEPENDENT ACCOUNTANT. THE AUDITED FINANCIAL STATEMENTS ARE REVIEWED BY THE BOARD OF DIRECTORS ANNUALLY AND ANY QUESTIONS OR CONCERNS REGARDING THE STATEMENTS ARE ADDRESSED BY THE INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. LATE FILED RETURN DUE TO CCH SOFTWARE OUTAGE