2018-01-08T09:54:48-06:00 2017-06-30 450250958 EIDE BAILLY LLP 4310 17TH AVE S PO BOX 2545 FARGO ND 581082545 990 2016-07-01 450308484 Tioga Medical Center TIOG 7016643305 PO Box 159 Tioga ND 58852 Randall K Pederson CEO 7016643305 2017-12-14 1 Lisa Chaffee CPA P00193453 7012398500 2017-12-11 209.243.15.107 2017-12-14 17:57:04 CS P 66CC91E6B7F11C4783FFFA5645E675327CB67316 66CC91E6B7F11C4783FFFA5645E675327CB67316 2016 2021-01-29 14:40:06Z Randall K Pederson PO Box 159 Tioga ND 58852 12178344 0 X www.tiogahealth.org X 1960 ND Health care and nursing care services 8 7 169 150 0 0 1442641 746767 10392107 11306637 113005 39829 123373 85111 12071126 12178344 500 500 0 0 6187241 6453294 0 0 0 5493470 5199636 11681211 11653430 389915 524914 18832522 18809085 9487392 8846987 9345130 9962098 X The mission of Tioga Medical Center is to address the health care needs of the community through providing quality health care and promoting education and wellness. 1 0 5429852 6310446 Tioga Medical Center provides delivery of healthcare services over eastern Williams county, Burke County and western Mountrail county of the state of North Dakota.Requirements of the IRS community benefit standard for tax-exempt organizations are integral to Tioga Medical Center's larger charitable mission of improving health and quality of life. Specifically, an independent board including community leaders, business experts and consumer representatives governs Tioga Medical Center. The Board has a history of commitment to acting with the highest integrity. For example:-Policies on confidentiality of patient and corporate information are reviewed annually as a component of mandatory education, and a confidentiality statement is signed and/or reviewed annually by all employees and board members.-Board members and key employees review and sign a conflict of interest statement annually.-Tioga Medical Center's code of conduct is published in its employee handbook and included in general orientation of all new employees and volunteers.Tioga Medical Center also makes medical care accessible to the entire community it serves. Tioga Medical Center operates a 24 hour emergency room and provides emergency care regardless of ability to pay. Tioga Medical Center had 1458 emergency room visits during the past fiscal year. Tioga Medical Center provides clinical services needed to operate the emergency room.In addition, Tioga Medical Center provides non-emergency services to the community it serves. It makes these services accessible to the community through participation in government programs like Medicare and Medicaid and by offering assistance through the Tioga Medical Center's uncompensated care program.Tioga Medical Center's uncompensated care (charity care) program provides free services to patients who lack the resources to be fully responsible for the health care they receive. The uncompensated care program is designed to ensure the entire community served by Tioga Medical Center has access to needed healthcare services. The Tioga Medical Center administration oversees services delivered under the uncompensated care program, including assessing community needs, approving eligibility criteria and monitoring the effectiveness of the program in providing community access to medical care.Tioga Medical Center maintains records to identify and monitor the level of care provided under the uncompensated care program. These records include the amount of charges foregone for services and supplies furnished under its charity care program. Tioga Medical Center had costs for charity care for the year ended June 30, 2017 of approximately $11,000.Tioga Medical Center takes its mission to improve the health and quality of life of the people it serves a step further by reaching out to meet the broad needs of the community. It strives to identify the community needs beyond basic healthcare, and then respond to them, aiming to make a positive, life-enhancing difference in the community. For example, many employees and Board members of Tioga Medical Center are actively involved in volunteer organizations that serve to protect the community, such as the Tioga Fire & Ambulance Department. As a small community, it is vital for people to come to the aid, as volunteers, when people are in need of assistance. Tioga Medical Center allows its employees to leave the workplace to tend to the emergency needs of the community we serve.The Tioga Medical Center, located at Tioga, North Dakota, is a provider of integrated healthcare delivery services consisting of a 25 bed Medicare designated Critical Access Hospital (CAH). The Tioga Medical Center CAH is a Level V designated trauma center. Within the CAH, acute care services are provided, along with swingbed services. 1955424 2762139 Attached to the CAH is a 30 bed skilled nursing facility. This facility provides skilled and long term care services to its residents. 2466345 1958271 The Medical Center also operates three clinics located in Tioga, Ray, and Powers Lake. These clinics are Medicare and Medicaid designated provider-based rural health clinics. Within the clinics, they employ one Family Medicine Physician, two Physician Assistants and two Family Nurse Practitioner. These practitioners provide physician related services at these clinics, as well as to the CAH and SNF. 201146 500 275781 Finally, attached to the Nursing home is a 22 unit independent living unit. The organization also has a Foundation that distributes scholarships. 201146 500 275781 10052767 1 1 0 0 0 0 0 0 1 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 12 0 1 169 1 0 0 0 0 0 0 0 0 0 0 X 8 7 1 0 0 0 1 1 0 1 0 0 0 1 1 1 1 1 1 1 1 0 X Ryan Mickelsen 7016643305 PO Box 159 Tioga ND 58852 David Rust Chair (July-March) 1.00 X X 0 0 0 James Booth Dir.(July-March)/Chair(April-June) 1.00 X X 0 0 0 David Grubb Vice-Chair (July-March) 0.50 X X 0 0 0 Harlan Germundson SecTreasurer (July-March)/Vice-Chair (April-June) 0.50 X X 0 0 0 Brian Longie-DirectorJuly-Mar Secretary/Treasurer (April-June) 0.50 X X 0 0 0 David Guttormson Director (July-March) 0.50 X 0 0 0 Kirk Odegaard Director 0.50 X 0 0 0 Mike Steffan Director (July-December) 0.50 X 0 0 0 Scott Sundhagen Director 0.50 X 0 0 0 Carolyn Eide Director (April-June) 0.50 X 0 0 0 Brodie Odegaard Director (April-June) 0.50 X 0 0 0 Arlene Grubb Director (April-June) 0.50 X 0 0 0 Lee Olson Director (April-June) 0.50 X 0 0 0 Randall K Pederson President/CEO 40.00 X 148086 0 8857 Ryan Mickelsen VP/CFO/COO 40.00 X 119593 0 8526 Robert Rotering Physician 40.00 X 305689 0 9602 Jeffrey Moberg Jr Physician Assistant 40.00 X 258050 0 10353 Nancy Carlson Nurse Practitioner 32.00 X 111521 0 6619 Lorena Mitchell Nurse Practitioner 40.00 X 123317 0 6058 1066256 0 50015 6 0 1 0 Northland Family Physicians 1451 44 Ave S STE A Grand Forks ND 58201 Contract Physicians 378720 Avant PO Box 60839 Charlotte NC 28260 Contracted Nursing Services 239533 Dakota Travel Nurse 1200 Collins Ave Mandan ND 58554 Contracted Nursing Services 191462 Shingobee Builders PO BOX 8 Loretta MN 55357 Construction 166937 4 324882 421885 746767 Patient & Resident Revenue 621110 11193959 11193959 Other Revenue 900099 112678 112678 11306637 28596 28596 66411 66411 18700 0 18700 18700 18700 10504 729 0 0 10504 729 11233 11233 12178344 11306637 0 124940 500 500 291929 291929 248906 248906 4989334 4486112 503222 30758 29229 1529 507656 446662 60994 384711 330435 54276 685 685 60731 60731 905756 905756 26924 26924 984140 506523 477617 201864 186422 15442 19348 7282 12066 36818 13929 22889 177325 177325 974725 974725 76992 40576 36416 Medical Supplies 873616 873616 Bad Debt Expense 824769 824769 35943 35943 11653430 10052767 1600663 0 1664200 2001428 45000 30000 1981127 2340237 94545 73029 54212 69653 21383859 9758607 12285757 11625252 2664681 2669486 43000 0 18832522 18809085 975817 827792 2860 2235 8508715 7935960 0 81000 9487392 8846987 X 9300130 9917098 45000 45000 9345130 9962098 18832522 18809085 524914 92054 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 14053 14053 723420 14396689 4944967 10175142 5458820 4575486 883334 790877 238154 552723 11625252 Third Party Payor Settlements 81000 81000 X 11445629 92054 -824769 -732715 12178344 0 12178344 10828661 0 10828661 824769 824769 11653430 Part IV, Line 2b: The Organization holds funds under an agency relationship for the residents of the nursing facility. Funds held as of June 30, 2017 and 2016 totaled $2,235 and $2,860. Part X, Line 2: The Medical Center is organized as a North Dakota nonprofit corporation and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The Medical Center is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Medical Center is subject to income tax on net income that is derived from business activities that are unrelated to their exempt purpose. The Medical Center has determined it is not subject to unrelated business income tax and has not filed an Exempt Organization Business Income Tax Return (Form 990T) with the IRS. The Medical Center believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the financial statements. The Medical Center would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. Part XI, Line 2d - Other Adjustments: Provision for Bad Debts in Expenses for Tax -824,769. Part XII, Line 4b - Other Adjustments: Provision for Bad Debts in Expenses for Tax 824,769. 1 1 X 1 X 1 X 0 0 0 11000 11000 0.00100 11000 11000 0.00100 57733 57733 0.00530 3123445 2656905 466540 0.04310 9151 9151 0.00080 3190329 2656905 533424 0.04920 3201329 2656905 544424 0.05020 0 824769 64332 2348762 2366165 -17403 X 1 1 1 1 Tioga Medical Center Hospital 810 Welo Street Tioga ND 58852 www.tiogahealth.org 5048 X X X X 3 provider based rural health clinics Tioga Medical Center Hospital 1 0 0 1 X X X X X X X X 15 1 0 1 1 X See Other Line 7d X X 1 15 1 See Other Line 7d 0 1 X 100.000000000000 200.000000000000 X 1 1 X X X X 1 X http://www.tiogahealth.org X http://www.tiogahealth.org X http://www.tiogahealth.org X X X X X X 1 X 0 X X X X 1 X 0 0 Tioga Medical Center Hospital Part V, Section B, Line 5: Tioga Medical Center distributed health needs surveys to patients at the hospital and clinic. Surveys were distributed at the senior citizens center. Public meetings were advertised in the local paper inviting all community members to participate. Special invitations were sent to members of the Community Ambulance Service, the community dentist, pharmacist, local public health representatives, chiropractor, and a representative of a community group home. Tioga Medical Center Hospital Part V, Section B, Line 6b: Tioga Medical Center's CHNA was conducted in collaboration with Upper Missouri Health District. Tioga Medical Center Hospital Part V, Section B, Line 7d: CHNA:http://www.tiogahealth.org/community-health-needs-assessment-report/Implementation Plan:http://www.tiogahealth.org/implementation-plan-2016-chna/ Tioga Medical Center Hospital Part V, Section B, Line 11: Tioga Medical Center did not take action on the identified needs of Cost of Health Insurance: Tioga Medical Center is a participating provider in Medicaid Expansion, is an HPE provider (presumptive eligibility) as well as has an uncompensated plan in place that accepts applications up to 200% of poverty level.Tioga Medical Center is addressing teenage use and abuse of alcohol, drugs, and teen pregnancy thru partnerships with the school systems in our service area, partnerships with law enforcement in our service area, providing education to the youth in service area thru informative guides and public lectures. Tioga Medical Center is addressing the need of services enabling elderly to stay in their home by partnering with Mercy Home Health Services to provide home health services, partnering with Wildrose Public Transportation to provide transportation services to the elderly in the community, as well as providing educational materials to the senior citizens organizations in our service area on these services. Tioga Medical Center Hospital Part V, Section B, Line 16j: If a patient does not have financial resources, the hospital asks if they have applied for medical assistance. Financial assistance is discussed with ER patients upon discharge and discussed upon admissions for all other services. Follow-up letters are sent separate from the bills on accounts that have not had payments for 90 days to remind patients that there is a charity care program available to them.A charity care application is sent with patient statements after 90 days. 1 1 - Tioga Medical Center Long Term Care 810 Welo Street Tioga ND 58852 Long term care Part I, Line 3c: Charity care is 100% write off at 100% of the federal poverty guidelines with a sliding fee discount for persons earning between 100%-200% of the federal poverty guideline. Part I, Line 7: Charity care expense was converted to cost on line 7a based on an overall cost-to-charge ratio addressing all patient segments. Health professionals education, line 7f, reflects actual expenses recorded to the general ledger. Subsidized health service, line 7g, was calculated based on information from the Medicare Cost Report. Cash and in kind contributions, line 7i, was calculated based on wages paid to staff providing EMS services. Part I, Ln 7 Col(f): The amount of bad debt expense removed from the denominator of the calculation was $824,769. Part III, Line 2: Bad debt expense is reported net of discounts and contractual adjustments. A payment on an account which was previously written off reduces bad debt expense in the current year. Part III, Line 3: The estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's charity care policy was calculated by applying the estimated percentage of the service area below the poverty guideline (7.8%) to the amount of bad debt expense. This estimate is due to a lack of information received from patients who may otherwise be eligible for the Organization's financial assistance policy, however, because of missing information they are otherwise classified as bad debt. Part III, Line 4: The footnote to the Organization's financial statements can be found on pages 8 and 9 of the attached audited financial statements. Part III, Line 8: Medicare allowable cost is based on the Medicare cost report. The Medicare cost report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services.All of the Medicare shortfall should be treated as a community benefit. The Organization treats individuals regardless of the ability to pay. Most of the Medicare shortfall comes from the nursing home. The elderly are an underserved population who experience issues with access to healthcare services. It is a community benefit to be able to treat them at the local nursing home. Part III, Line 9b: The billing and collection policy applies to all patients. Every effort is made to determine if a patient may be eligible for charity care. No collection actions are taken if a patient is in the process of applying for charity care or has been accepted for charity care. Any personal portion due would follow normal collection procedures. Part VI, Line 2: In addition to a Community Health Needs Assessment conducted during FY 16, a formal needs assessment has been conducted where providers are able to bring identified needs to administration. The identified needs arereviewed by the physicians/providers as well. The request is analyzed to see if it can be cost-justified; then, the request is brought to the Board of Directors for approval. Mobile MRI services, Dexa Scan, Diabetes Education, In-house CT scanning, an OR remodel, eEmergency, and the purchase of an ablasion machine have all been added in the past five years through this process. Part VI, Line 3: If a patient does not have financial resources, the hospital asks if they have applied for medical assistance. Financial assistance is discussed with ER patients upon discharge and discussed upon admissions for all other services. Follow-up letters are sent separate from the bills on accounts that have not had payments for 90 days to remind patients that there is a charity care program available to them. Part VI, Line 4: The hospital's primary service area consists of residents in Williams County, with some residents of Mountrail/Burke Counties. The primary industries in this area are agriculture, oil, and tourism. Williams County had an estimated population of 34,337 as of July 2016 according to census.gov. An estimated 9% of the population was 65 or older in 2016, and 7.8% were estimated below the poverty level in 2016. Part VI, Line 5: Tioga Medical Center furthers its exempt purpose by promoting the health of the community through:* Medical staff privileges are extended to all community providers* Surplus funds are reinvested into equipment and facility upgrade* The next closest hospital is 30 miles away from the organization - sole provider in the immediate area* Provide emergency care regardless of a patient's ability to pay* Employees serve on a voluntary ambulance and fire department and the organization allows the employees to serve those duties without punching out* Therapy departments talk to coaches about sports injuries and educate coaches on caring for injuries* Educate senior citizen groups on medical awareness topics* Diabetes education services are provided to patients of Tioga Medical Center at no cost to the patient. X 1 1 X X X 0 0 0 0 0 0 0 1 0 Randall K Pederson President/CEO 134094 0 1040 0 12952 0 1940 0 6917 0 156943 0 0 0 Robert Rotering Physician 294809 0 10880 0 0 0 3545 0 6058 0 315292 0 0 0 Jeffrey Moberg Jr Physician Assistant 256490 0 1560 0 0 0 3437 0 6917 0 268404 0 0 0 Part I, Line 1a The spending account is for a continuing medical education allowance. The doctors have an allowance of $4,000 per year for their continuing education. The board provides direction on the CME allowance. Review of the allowance is completed during each recruitment phase. An estimate is determined by the board based on a reasonable estimate provided by the recruiters. Total expenditures per person are reviewed and examined on an industry standard basis. These numbers are reevaluated each time a new doctor is recruited. Part I, Line 7 All employees receive a holiday bonus based on productive hours. Mary Jo Hove Family of board member David Grubb 67920 Mary receives compensation as a lab tech. 0 Craig Odegaard Family of board member Kirk Odegaard 44274 Craig receives compensation as a maintenance employee. 0 Haley Alberts Family of board member Kirk Odegaard 16694 Haley receives compensation as a coder. 0 Lori Olson Family of president Randall Pederson 62831 Lori receives compensation as a registered nurse. 0 Karen Pederson Family of president Randall Pederson 31306 Karen receives compensation as an activity aide. 0 Amanda Mickelsen Family of vice president Ryan Mickelsen 25881 Amanda receives compensation as a registered nurse. 0 Form 990, Part III, line 2 TMC, in collaboration with The University of North Dakota, began providing outpatient surgical services October 2016. Services are offered two days per month. Form 990, Part VI, Section A, line 1 Board Chair does not vote. Form 990, Part VI, Section A, line 2 Harlan Germundson and David Grubb had a business relationship. Form 990, Part VI, Section A, line 6 An individual interested in becoming a member must complete an application and submit to the Board of Directors for approval. There is only one class. Form 990, Part VI, Section A, line 7a An annual meeting is held in March of each year in which the members may elect board members if applicable. The members also vote on approval of the audited financial statements. Form 990, Part VI, Section A, line 8b The Physician Interview Committee does not take minutes as the committee meets only for physician interviews. This committee reports their recommendation to the full Board of Directors. Form 990, Part VI, Section B, line 11b A copy of the return is given to each board member and discussed at a regular monthly meeting. The board must approve the form before it is signed by the facility's representative. Form 990, Part VI, Section B, line 12c The policy covers all board members and officers. The Administration will determine if a conflict exists. In the event of a conflict, said board members abstain from related motions/votes but may still participate in discussions. Form 990, Part VI, Section B, line 15 Annual salary survey results from the North Dakota Hospital Association are reviewed. Related organization's 990 compensation information is also reviewed. The compensation of the President/CEO and Vice President/CFO and relevant employees is examined by the Board of Directors and adjusted annually if deemed necessary. This process is documented in the board minutes. Form 990, Part VI, Section C, line 19 The governing documents, conflict of interest policy and financial statements are available to the public upon request.