2017-08-11T09:17:00-05:00 2016-09-30 390758449 Wipfli LLP PO Box 12237 Green Bay WI 543072237 990 2015-10-01 061745397 Oconto Hospital and Medical Center OCON 9208351100 PO BOX 357 OCONTO WI 54153 Laura Hieb CEO 9208351100 2017-08-08 1 Terri Rexrode CPA MST P00096513 9206620016 2017-08-08 2015 2021-01-29 14:40:06Z Bellin Health Oconto Hospital Laura Hieb PO BOX 357 OCONTO WI 54153 19513095 0 X www.ocontohospital.org X 2005 WI OCONTO HOSPTIAL & MEDICAL CENTER, INC. (THE ORGANIZATION) IS YOUR HOME TOWN HOSPITAL, CREATED TO MAKE OUTSTANDING HEALTHCARE CONVENIENT. BACKED BY THE RESOURCES OF BELLIN HEALTH, THE ORGANIZATION OFFERS OUTSTANDING HOSPITAL-BASED, EMERGENCY AND PRIMARY CARE SERVICES. THE ORGANIZATION OFFERS THE CARE YOU NEED WHERE YOU WANT IT. 7 3 91 13 0 0 257364 201050 19072124 19243152 2997 1119 59458 30755 19391943 19476076 0 0 0 0 5892695 6479171 0 0 0 9034436 8604908 14927131 15084079 4464812 4391997 25080641 26108187 17248485 14039995 7832156 12068192 X THE MISSION OF OCONTO HOSPITAL & MEDICAL CENTER IS TO PROVIDE 24-HOUR LOCAL ACCESS TO EFFECTIVE, EFFICIENT HEALTH, WELLNESS AND PREVENTATIVE SERVICES TO OCONTO AND THE SURROUNDING RURAL COMMUNITIES. TOWARD THIS PURPOSE, OCONTO HOSPITAL & MEDICAL CENTER WORKs IN PARTNERSHIP WITH THE COMMUNITY, THE CITIZENS HOSPITAL FOUNDATION AND BELLIN HEALTH. 0 0 12533393 19240711 AS A KEY REGIONAL ASSET, THE ORGANIZATION IS A NOT-FOR-PROFIT HEALTHCARE PROVIDER. THE ORGANIZATION PROVIDES ACUTE HOSPITAL, EMERGENCY AND URGENT CARE TO RESIDENTS OF OCONTO, WISCONSIN AND THE SURROUNDING COMMUNITIES. DURING THE PERIOD OF OCTOBER 1, 2015 TO SEPTEMBER 30, 2016, 316 INPATIENT DAYS WERE PROVIDED AND 143 SWING BED DAYS WERE PROVIDED. THE NUMBER OF OUTPATIENTS REGISTERED DURING THE SAME 12 MONTH PERIOD WAS 17,045. 12533393 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 0 0 91 1 0 0 0 0 0 0 0 0 0 0 X 7 3 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X SARA ARNDT 9204457260 2020 SOUTH WEBSTER AVENUE GREEN BAY WI 54301 GEORGE KERWIN BOARD MEMBER 0.50 50.00 X 0 910203 27477 John Honish BOARD MEMBER 0.50 X 0 0 0 Sara Arndt BOARD MEMBER 0.50 40.00 X 0 71768 24997 CHRISTINE WOLESKE Former CEO/BOARD MEMBER 0.50 50.00 X X 0 405067 35558 DAVID HONISH Chairperson 0.50 X X 0 0 0 RODNEY JOHNSON SECRETARY/TREASURER 0.50 X X 0 0 0 LAURA CORMIER VP OF OPERATIONS 50.00 X 142990 0 20691 Laura Hieb CEO 0.50 50.00 X 0 301191 27292 Charles Heyka MD President of Medical Staff 50.00 X 223712 0 33740 Lindsey Baade Nurse Practitioner 50.00 X 112043 0 3398 Jennifer LaPlant Pharmacist 50.00 X 141958 0 31593 Robert Bivins MD Physician 50.00 X 241237 0 32586 Ryan MacDonald Physician Assistant 50.00 X 114470 0 23221 976410 1688229 260553 6 0 1 0 Bellin Memorial Hospital Inc 744 S Webster Avenue Green Bay WI 54305 Management Services 1136874 Michael Downs MD PO Box 72062 Cedarburg WI 53012 ContRACTED ED PHYSICIAN SERVICES 177544 JIN KIM MD 155 Orange Road Paseo Unit 4064 Pasadena CA 91105 CONTRACTED ED PHYSICIAN SERVICES 173799 Thario Cleaning Service 2936 Holmgren Way Green Bay WI 54304 Housekeeping Services 125008 4 191500 9550 201050 NET PATIENT REVENUE 621300 19118510 19118510 RENT FROM AFFILIATES 900099 122201 122201 miscellaneous Revenue 900099 2441 2441 19243152 1119 1119 67774 37019 30755 30755 30755 19476076 19240711 0 34315 X 421134 257452 163682 4894169 4701104 193065 227212 215993 11219 586799 561002 25797 349857 326774 23083 25000 25000 1962019 723511 1238508 78932 153 78779 118243 83291 34952 42927 5411 37516 236576 228331 8245 42982 27535 15447 20778 8989 11789 486615 486615 1443157 1335965 107192 16888 13602 3286 Supplies expense 2533703 2532249 1454 Equipment rent/maintena 796720 780095 16625 Bad debt expense 712211 712211 Dues & subscriptions 57683 10058 47625 30474 9667 20807 15084079 12533393 2550686 0 929801 4587858 2967593 2118216 508795 460479 35938 108996 27388075 8922092 19845350 18465983 793164 366655 25080641 26108187 1473066 1309871 12716663 12249995 3058756 480129 17248485 14039995 X 7589742 11981739 242414 86453 7832156 12068192 25080641 26108187 X 4391997 -155961 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 661050 661050 15005641 3084243 11921398 171971 95050 76921 11549413 5742799 5806614 18465983 DUE TO AFFILIATE 480129 480129 18609384 -712211 -712211 19321595 154481 154481 19476076 14408887 37019 37019 14371868 712211 712211 15084079 Part XI, Line 2d - Other Adjustments: Provision for bad debts -712,211. Part XI, Line 4b - Other Adjustments: RENTAL DEPRECIATION -37,019. oconto memorial hospital citizens foundation, inc. revenue 191,500. Part XII, Line 2d - Other Adjustments: RENTAL DEPRECIATION 37,019. Part XII, Line 4b - Other Adjustments: Provision for bad debts 712,211. 1 1 X 1 X 1 X 1 0 1 1 118166 118166 0.00820 1972766 1716032 256734 0.01790 2090932 1716032 374900 0.02610 3751 3751 0.00030 9947 9947 0.00070 13384 13384 0.00090 27082 27082 0.00190 2118014 1716032 401982 0.02800 1 327617 3611210 3618647 -7437 X 1 1 1 1 Oconto Hospital & Medical Center Inc 820 Arbutus Ave Oconto WI 54153 1061 X X X Oconto Hospital & Medical Center Inc 1 0 0 1 X X X X X X X X 14 1 1 1 1 X www.ocontohospital.org X 1 15 1 www.ocontohospital.org 0 0 1 X 220.000000000000 400.000000000000 X X 1 1 X X X 1 X X X X 1 X 0 X X X X 1 X 0 0 Oconto Hospital & Medical Center, Inc. Part V, Section B, Line 5: Assessment team included health delivery systems serving the community, public health, law enforcement, education, employers, healthcare providers, county agencies, United Way, public officials and individual community members. Oconto Hospital & Medical Center, Inc. Part V, Section B, Line 6a: HSHS St. Clare Hospital, Oconto Falls, WI Oconto Hospital & Medical Center, Inc. Part V, Section B, Line 6b: Oconto County Public Health Oconto Hospital & Medical Center, Inc. Part V, Section B, Line 11: The Healthy Oconto County 2018 steering team held a community event in April, 2016 to review our current focus areas for improvement: Alcohol and Other Drugs Nutrition and Physical Activity Mental HealthThe event's purpose was to review updated county and state data on the focus areas and to determine if our focus and activity for improvement is still on target for improving health in the county. The full plan, available here, outlines a definition of each health focus area, why it was chosen, the overall goal, strategies and measures of success and key stakeholders.The concensus of the April event was to narrow the focus on the two areas below. The two primary health systems in the county have stepped forward to lead the groups. The groups will continue to assess county needs, seek out and add new members to engage in improving each of these focus areas. If interested in participating in the improvement work or learning more about either or both of these efforts please contact the individuals listed below: Alcohol and Other Drug Misuseo Group Leaders: Laura Cormier, Bellin Health Oconto Hospital Tel: 920-835-1101 Debbie Konitzer, Oconto County Public Health Tel: 920-834-7000 Nutrition and Physical Activityo Group Leaders: David Lally, HSHS St. Clare Hospital Tel: 920-848-6390 Debbie Konitzer, Oconto County Public Health Tel: 920-834-7000A full plan update and reassessment will occur in the fall of 2017. Oconto Hospital & Medical Center, Inc. Part V, Section B, Line 13b: A patient's liability is capped to 15% of annual income. A patient who receives any percentage of charity care based on their income, will not be responsible for more than 15% of their annual income. Oconto Hospital & Medical Center, Inc. Part V, Section B, Line 22d: The hospital looked at the average amount collected for all payers (including medicare and medicaid). Average collection rate was 44%. Any patient receiving Financial Assistance, will not be responsible for more than 44% of charges. Part I, Line 6a: Oconto Hospital and Medical Center is included in the Bellin Health Systems, Inc. Community Benefit Report. Part I, Line 7: AMOUNTS ARE CALCULATED BASED ON THE COST TO CHARGE RATIOS AND WORKSHEET 2 PROVIDED BY THE IRS. Part I, Ln 7 Col(f): BAD DEBT EXPENSE OF $712,211 INCLUDED ON FORM 990, PART IX, LINE 25 WAS EXCLUDED FROM THE DENOMINATOR PER INSTRUCTIONS WHEN CALCULATING THE PERCENT TOTAL EXPENSES ON SCHEDULE H. Part II, Community Building Activities: Coordination and support of local EMS - community disaster drill, mass casualty drill, education, smoke inhalation kits stocked at the hospital. Part III, Line 2: The bad debt expense at cost is calculated based on the cost to charge ratios. Part III, Line 3: The hospital utilizes HFMA #15 therefore none of the bad debt would be deemed charity care. Part III, Line 4: The attached financial statements do not contain a specific bad debt expense footnote. However, the summary of significant accounting policies describes the provision for bad debt on pages 12 and 13 of the financial statements.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 a portion of the bill), Bellin Health Systems 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 allowances for doubtful accounts. Part III, Line 8: THE AMOUNTS REPORTED FOR MEDICARE WERE CALCULATED USING A COST TO CHARGE RATIO. THE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT FOR THE FOLLOWING REASONS. IRS REV RUL 69-545 WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENT HEALTH BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. IN ADDITION, ELDERLY PATIENTS ARE OFTEN UNDERSERVED AND EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT EXEMPT HOSPITALS, CMS WOULD NEED TO PROVIDE THESE SERVICES. Part III, Line 9b: If a patient is known to qualify for charity care, the amount of charity care the patient receives is based on the patients income. We have a sliding scale that looks at your income as a % of the Federal Poverty Level. Income from 0-220% gets 100% charity care. Income 401% or more than the federal poverty level gets 0%. In between 220% and 400% is the sliding scale. Once qualified for charity care, this qualification is good for 6 months going forward. Part VI, Line 2: THE ORGANIZATION ANNUALLY REVIEWS THE OCONTO COUNTY HEALTH RANKINGS THROUGH THE UW POPULATION HEALTH DEPARTMENT TO IDENTIFY AREAS THAT HAVE MADE IMPROVEMENTS AND AREAS FOR IMPROVEMENT OPPORTUNITIES WITHIN THE SCOPE OF THE ORGANIZATION'S SERVICES Part VI, Line 3: INFORMATION ON GOVERNMENT ASSISTANCE PROGRAMS AND THE CHARITY CARE PROGRAM IS MADE AVAILABLE TO PATIENTS IN THE EMERGENCY ROOM AND AT THE TIME OF REGISTRATION. ADDITIONALLY, THE INFORMATION IS INCLUDED IN PATIENT STATEMENTS AND LETTERS FROM THE BILLING OFFICE. Part VI, Line 4: THE ORGANIZATION IS LOCATED IN THE CITY OF OCONTO, WISCONSIN. ITS PRIMARY SERVICE AREA IS THE CITY OF OCONTO AND ITS SECONDARY SERVICE AREA SPREADS TO THE NORTHERN PORTION OF OCONTO COUNTY AND SOUTHERN MARINETTE COUNTY. THE CITY OF OCONTO HAS A POPULATION OF 4,500. 17% OF THE POPULATION IS OVER AGE 65 AND 8.8% OF THE POPULATION IS BELOW THE POVERTY LINE. Part VI, Line 5: THE ORGANIZATION IS A STEERING TEAM MEMBER OF THE HEALTHY OCONTO COUNTY IMPROVEMENT WORK ALONG WITH HSHS ST. CLARE HOSPITAL AND OCONTO COUNTY PUBLIC HEALTH. THE ORGANIZATION ACTIVELY PARTICIPATES IN THE OCONTO AREA CHAMBER OF COMMERCE BUSINESS EXPOR, COPPERFEST SPONSORSHIP, NEWCAP AND HUMANE SOCIETY FOOD DRIVES. IN ADDITION THE ORGANIZATION IS A SOLE COMMUNITY HOSPITAL WITH AN EMERGENCY ROOM AVAILABLE 24/7 TO ALL. Part VI, Line 6: THE ORGANIZATION, IN PARTNERSHIP WITH BELLIN HEALTH SYSTEMS, INC., CONTINUES TO SERVE IT'S COMMUNITY. X X 0 0 0 0 0 0 0 0 0 GEORGE KERWIN BOARD MEMBER 0 546445 0 348100 0 15658 0 10400 0 17077 0 937680 0 0 CHRISTINE WOLESKE Former CEO/BOARD MEMBER 0 324705 0 79948 0 414 0 16752 0 18806 0 440625 0 0 LAURA CORMIER VP OF OPERATIONS 116802 0 25000 0 1188 0 10224 0 10467 0 163681 0 0 0 Laura Hieb CEO 0 240921 0 60000 0 270 0 17295 0 9997 0 328483 0 0 Charles Heyka MD President of Medical Staff 222938 0 0 0 774 0 12867 0 20873 0 257452 0 0 0 Jennifer LaPlant Pharmacist 141796 0 0 0 162 0 8127 0 23466 0 173551 0 0 0 Robert Bivins MD Physician 240823 0 0 0 414 0 10884 0 21702 0 273823 0 0 0 A Wisconsin Health & Educational Facilities Authority 391337855 2011-08-18 14000000 Facility and service expansion 0 0 0 A 466668 36149 132033 13831818 2012 0 0 1 1 A 0 0 0 0 0 0 1 A 0 1 0 0 0 0 0 0 A 1 Schedule K Supplental Information IN FEBRUARY 2015, THERE WAS AN AMENDMENT TO THE BOND INDENTURE AND LOAN AGREEMENT FOR THE REISSUANCE OF THE OUTSTANDING PRINCIPAL OF THE BONDS TO AMEND THE INTEREST RATE AND DEMAND DATE OF THE BONDS. Form 990, Part VI, Section A, line 2 John Honish and David Honish have a family relationship. Form 990, Part VI, Section A, line 6 The organization has two members, Bellin Memorial Hospital, Inc. and Oconto Memorial Hospital Citizens Foundation, Inc. Form 990, Part VI, Section A, line 7a The members of the organization have the power to appoint/elect the Board of Directors. Form 990, Part VI, Section A, line 7b The members also have the power to approve, but not limited to, the philosophy, mission, and value of the organization, strategic plans, the annual operating and capital budget, amendments or restatements of the Articles of Incorporation and Bylaws. Form 990, Part VI, Section B, line 11 THE FORM 990 IS REVIEWED IN DETAIL BY SENIOR ADMINISTRATION AND IS PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO FILING. Form 990, Part VI, Section B, line 12c THE ORGANIZATION REQUESTs AN ANNUAL UPDATE FROM ALL Board MEMBERS WHO SIGN THE POLICY. ALL DOCUMENTS ARE PROVIDED BACK TO ADMINISTRATION AND REVIEWED. IF THERE IS A CONFLICT OF INTERST, THE CORPORATE COMPLIANCE OFFICER IS NOTIFIED. MEMBERS OF THE BOARD WHO HAVE A CONFLICT OF INTEREST WITH A BOARD DECISION ABSTAIN FROM VOTING ON THE ISSUE. Form 990, Part VI, Section B, line 15 COMPENSATION OF KEY EXECUTIVES ARE SET BY THE EXECUTIVE COMMITTEE OF THE BOARD WITHOUT CONFLICT OF INTEREST AND IS SUPPORTED BY MARKET DATA FROM SURVEYS and an independent consultant's report. Form 990, Part VI, Section C, line 19 THE ORGANIZATION CONSIDERS THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS PROPERTY OF THE ORGANIZATION AND THEREFORE ARE NOT AVAILABLE TO THE PUBLIC. Form 990, Part IX, line 11g Intercompany IT Services: Program service expenses 0. Management and general expenses 819,859. Fundraising expenses 0. Total expenses 819,859. Intercompany Mangement Charges: Program service expenses 0. Management and general expenses 418,649. Fundraising expenses 0. Total expenses 418,649. Contracted Labor - Other: Program service expenses 218,580. Management and general expenses 0. Fundraising expenses 0. Total expenses 218,580. Contracted Labor - Environmental Services: Program service expenses 209,595. Management and general expenses 0. Fundraising expenses 0. Total expenses 209,595. Contracted Labor - Emergency Department: Program service expenses 295,336. Management and general expenses 0. Fundraising expenses 0. Total expenses 295,336. Form 990, Part XI, line 9: change in interest in oconto memorial hospital citizens' foundation, inc. -155,961. Form 990, Part XI, Line 2B-2C THE ORGANIZATION IS INCLUDED IN THE CONSOLIDATED AUDIT OF BELLIN HEALTH SYSTEMS, INC. THE BOARD OF DIRECTORS OF BELLIN HEALTH SYSTEMS, INC. ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND SELECTION OF AN INDEPENDENT AUDITOR. LAKE MICHIGAN HEALTH SERVICES INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54305 391512903 SUPPORT PURPOSES OF BELLIN MEMORIAL HOSPITAL WI 501(c) Line 11b, II Bellin Health Systems Inc 1 BELLIN COLLEGE INC 3201 EATON ROAD GREEN BAY WI 54311 391620530 NURSING and Radiologic Science COLLEGE WI 501(c) Line 2 Bellin Health Systems Inc 1 THE BELLIN HEALTH FOUNDATION INC PO BOX 23400 GREEN BAY WI 54305 391809171 FOUNDATION WI 501(c) Line 7 Bellin Health Systems Inc 1 BELLIN PSYCHIATRIC CENTER INC PO BOX 23725 GREEN BAY WI 54305 391657627 PPSYCHIATRIC HOSPITAL WI 501(c) Line 3 Bellin Health Systems Inc 1 BELLIN MEMORIAL HOSPITAL INC PO BOX 23400 GREEN BAY WI 54305 391900586 ACUTE CARE HOSPITAL WI 501(c) Line 3 Bellin Health Systems Inc 1 BELLIN HEALTH SYSTEMS INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54305 391512904 SUPPORT OF HEALTHCARE ORGANIZATIONS WI 501(c) Line 11b, II N/A 0 Unity Limited Partnership 2366 Oak Ridge Circle De Pere WI 54115 391750729 Hospice, Palliative & Bereavement Services WI 501(c) Line 9 Bellin Memorial Hospital Inc 1 BELLIN ORTHOPEDIC SURGERY CENTER LLC 2223 LIME KILN RD GREEN BAY WI 54311 264677834 AMBULATORY ORTHOPEDIC SURGERY WI N/A D1 SPORTS TRAINING OF GREEN BAY LLC 7115 SOUTH SPRINGS DRIVE FRANKLIN TN 37067 454848172 SPORTS TRAINING TN N/A BEL-REGIONAL HOME MEDICAL INC 617 S ROOSEVELT GREEN BAY WI 54301 391504766 DURABLE MEDICAL EQUIPMENT, RETAIL PHARMACY, FITNESS WI N/A C 0 BELLIN INVESTMENTS INC PO BOX 23400 GREEN BAY WI 54305 391564939 OTHER WI N/A C 0 0 0 0 0 1 0 0 0 0 1 0 0 1 0 1 1 0 0 0 Bellin Memorial Hospital Inc E 12249995 FMV Bel-Regional Home Medical Inc J 120000 FMV Bellin Memorial Hospital Inc M 1233599 FMV Bellin Memorial Hospital Inc P 4250000 FMV Bellin Memorial Hospital Inc O 657118 FMV