2017-05-15T09:29:59-05:00 2016-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2015-07-01 390890676 ST CROIX REGIONAL MEDICAL CENTER STCR 7154830556 235 STATE STREET ST CROIX FALLS WI 54024 SALLY BAJAK CFO 7154830556 2017-05-09 1 KACIE MCEWEN P01599614 6123764500 2015 2021-01-29 14:40:06Z DAVE DOBOSENSKI 235 STATE STREET ST CROIX FALLS WI 54024 99364246 0 X WWW.SCRMC.ORG X 1954 WI TO PROVIDE QUALITY HEALTHCARE SERVICES TO ALL RESIDENTS OF THE SERVICE AREA. 9 9 701 141 0 0 140309 127257 86067301 96341956 22905 -124934 1608057 2931234 87838572 99275513 8947 10744 0 0 29953548 33681157 0 0 0 48730724 53533691 78693219 87225592 9145353 12049921 62943736 69017853 22175837 16200883 40767899 52816970 X THE MISSION OF SCRMC IS TO PROVIDE THE HIGHEST QUALITY, ACCESSIBLE, INTEGRATED, COST EFFECTIVE CARE FOR INDIVIDUALS AND FAMILIES SERVED. 0 0 50630560 0 61095116 OUTPATIENT SERVICES - SURGICAL, LABORATORY, BASIC, AND ADVANCED RADIOLOGY PROCEDURES. DURING FISCAL YEAR 2016, THERE WERE 9,216 EMERGENCY ROOM VISITS RECORDED, 1,740 OUTPATIENT SURGERIES, AND 245,088 LAB TESTS COMPLETED. 20569874 10744 24821350 INPATIENT SERVICES - OBSTETRIC, MEDICAL-SURGICAL, INTENSIVE CARE, AND SHORT STAY INPATIENT CARE. DURING FISCAL YEAR 2016, THERE WERE 268 BIRTHS, 1,563 INPATIENT ADMISSIONS, AND A TOTAL OF 5,017 INPATIENT DAYS FOR AN AVERAGE LENGTH OF STAY OF 3.21 DAYS. 3915806 0 4725143 CONTRACT PHARMACY - ST. CROIX REGIONAL MEDICAL CENTER BECAME ELIGIBLE TO PARTICIPATE IN THE 340B DRUG PRICING PROGRAM, WHICH IS MANAGED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA) OFFICE OF PHARMACY AFFAIRS (OPA), RESULTING IN THE REALIZATION OF A CONTRACT PHARMACY SERVICE. PARTICIPATION IN THE 340B DRUG PRICING PROGRAM RESULTS IN SIGNIFICANT SAVINGS, ESTIMATED TO BE 20-50%, ON THE COST OF PHARMACEUTICALS FOR USE BY OUTPATIENTS OF THE FACILITY. THROUGH THIS PROGRAM, ST. CROIX REGIONAL MEDICAL CENTER IS ABLE TO REACH MORE ELIGIBLE PATIENTS AND PROVIDE MORE COMPREHENSIVE SERVICES. 4723975 0 5700347 ST. CROIX VALLEY PHARMACIES PROVIDE LOCAL PHARMACY CARE TO THE SERVICE AREA OF ST. CROIX REGIONAL MEDICAL CENTER. ST. CROIX VALLEY PHARMACIES IS THE SOLE MEMBER OF THE FOLLOWING COMMUNITY PHARMACIES: UNITY PHARMACY LOCATED IN THE UNITY CLINIC BUILDING NEAR BALSAM, WI, FREDERIC PHARMACY LOCATED IN THE FREDERIC CLINIC BUILDING IN FREDERIC, WI, AND ST. CROIX FALLS PHARMACY LOCATED IN THE ST. CROIX FALLS CLINIC BUILDING IN ST. CROIX FALLS, WI. 4723975 0 5700347 79840215 1 1 0 1 0 0 0 0 1 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 1 76 0 701 1 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 WI X X X SALLY BAJAK 7154830556 235 STATE STREET ST CROIX FALLS WI 54024 HARLEN HEGDAL CHAIR 2.00 X X 0 0 0 KRISTINE FUGE VICE CHAIR 0.50 X X 0 0 0 MICHAEL BUCHITE TREASURER 0.50 X X 0 0 0 JOSEPH RUEGEMER MD SECRETARY/CONTRACTED RVMC PHYSICIAN 0.50 X X 0 0 0 SARAH CORMELL TRUSTEE/CONTRACTED RVMC PHYSICIAN 0.50 X 0 0 0 ALLISON KARUN MD TRUSTEE/CONTRACTED RVMC PHYSICIAN 0.50 X 0 0 0 PATRICK MCDONOUGH MD TRUSTEE/CONTRACTED RVMC PHYSICIAN 0.50 X 0 0 0 DANIELLE REDBURN MD TRUSTEE/CONTRACTED RVMC PHYSICIAN 0.50 X 0 0 0 STEVE TESCH TRUSTEE 0.50 X 0 0 0 WILLIAM SCHULTZ MD TRUSTEE CONTRACTED RVMC PHYSICIAN THRU 12/15 0.50 X 0 0 0 DAVE DOBOSENSKI CEO 40.00 X 523560 0 43064 JOHN TREMBLE CFO & VP 40.00 X 226999 0 14324 GURDESH BEDI PHYSICIAN OF SCRMC 40.00 X 775787 0 16326 STEPHEN DENNIS PHYSICIAN OF SCRMC 40.00 X 271645 0 40717 MUHAMMAD KHAN PHYSICIAN OF SCRMC 40.00 X 297937 0 34445 CLAUDIO NUNES PHYSICIAN OF SCRMC 40.00 X 364384 0 56731 MINGZHU XU PHYSICIAN OF SCRMC 40.00 X 271449 0 41592 2731761 0 247199 31 0 1 0 RIVER VALLEY MEDICAL CENTER 208 SOUTH ADAMS STREET ST CROIX FALLS WI 54024 PHYSICIAN SERVICES 8995987 VOYAGEUR RADIOLOGY LLC 9975 DELLWOOD ROAD STILLWATER MN 55082 RADIOLOGY SERVICES 1042539 ALLINA HEALTH SYSTEM PO BOX 9383 MINNEAPOLIS MN 55440 EMR SUPPORT SERVICES 1042499 ST CROIX VALLEY ANESTHESIA PO BOX 45 OSCEOLA WI 54024 CRNA SERVICES 1008933 CMDI PO BOX 158 MILACA MN 56353 RADIOLOGY SERVICES 899809 15 127257 127257 PATIENT SERVICES 624100 85583921 85583921 CONTRACT PHARMACY 624100 4725143 4725143 FREDERIC PHARMACY 624100 2581804 2581804 SCF PHARMACY 624100 1744828 1744828 UNITY PHARMACY 624100 1373699 1373699 332561 16 332545 96341956 -89010 -89010 84023 7447 76576 76576 76576 35924 -35924 -35924 -35924 73079 45362 27717 27717 EHR PAYMENT 900099 1618389 1618389 MISCELLANEOUS 900099 934272 934272 JOINT VENTURE REVENUE 900099 274280 274280 2826941 99275513 96009411 0 3138845 X 10744 10744 474498 474498 29412663 25533564 3879099 1276330 1108001 168329 457364 397044 60320 2060302 1788578 271724 194551 194551 44984 44984 5250 5250 18442155 17627731 814424 173506 28281 145225 366175 215963 150212 760432 694274 66158 2096352 1913969 182383 111976 88738 23238 326489 285146 41343 250190 228423 21767 3496453 3192262 304191 -18336 -21334 2998 MEDICAL SUPPLIES 19017328 18941048 76280 OTHER EXPENSES 4311556 3905151 406405 BAD DEBTS 3471555 3471555 COLLECTIONS 182117 182117 300958 248960 51998 87225592 79840215 7385377 0 9649812 15726092 831879 515988 16238342 15855947 139704 75589 2323996 2635121 504897 633444 60255007 31824126 28357977 28430881 2725886 3023771 1335156 1477331 715237 623689 120850 20000 62943736 69017853 10987967 9372223 6400536 4175606 375000 247000 4412334 2406054 22175837 16200883 X 40767899 52816970 40767899 52816970 62943736 69017853 12049921 -850 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 1 0 0 1 5250 1 0 5250 0 PART II-B, LINE 1: WE HAVE HIRED STRATEGIC HEALTHCARE TO ASSIST US IN DISCUSSING CAH DESIGNATION FOR 10 MILE HOSPITALS. 1 3697 0 3697 0 0 1235979 1235979 34931073 15937657 18993416 1462075 846309 615766 21531202 15040160 6491042 1094678 1094678 28430881 DEFERRED COMPENSATION PLAN 1077563 ASSET RETIREMENT OBLIGATION 236491 THIRD PARTY PAYOR 1092000 2406054 X 95740483 -3445958 -3445958 99186441 89072 89072 99275513 83847796 93759 93759 83754037 3471555 3471555 87225592 PART IV, LINE 1B: ST. CROIX REGIONAL MEDICAL CENTER IS AN AGENT FOR A CHECKING ACCOUNT THAT HOUSES FUNDS FOR THE WEST CENTER REGIONAL TRAUMA ADVISORY COUNCIL. THE MONIES ARE USED TO FUND TRAUMA TRAINING FOR THOSE PARTICIPATING HOSPITALS WITHIN THE COUNCIL. PART X, LINE 2: THE MEDICAL CENTER IS A NONPROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE MEDICAL CENTER IS ALSO EXEMPT FROM STATE INCOME TAXES. THE MEDICAL CENTER'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE MEDICAL CENTER IS NOT AWARE OF ANY ADDITIONAL ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR EXCISE OR OTHER TAXES THAN ARE CURRENTLY FILED IN THE TAX RETURN. THE MEDICAL CENTER IS THE SOLE CORPORATE MEMBER OF SCV PHARMACIES. SCV PHARMACIES IS TREATED AS A 501(C)(3) FOR FEDERAL TAX PURPOSES AS IT COMES UNDER THE MEDICAL CENTER'S TAX-EXEMPT STATUS. SCV PHARMACIES IS THE SOLE MEMBER OF FREDERIC, UNITY, AND SCF PHARMACY, SO ALL OF THESE ENTITIES ARE ALSO TREATED AS A 501(C)(3) FOR FEDERAL TAX PURPOSES UNDER THE MEDICAL CENTER'S TAX-EXEMPT STATUS. SCV EMS IS A NONPROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. SCV EMS IS ALSO EXEMPT FROM STATE INCOME TAXES. SCV EMS'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. SCV EMS IS NOT AWARE OF ANY ADDITIONAL ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR EXCISE OR OTHER TAXES THAN ARE CURRENTLY FILED IN THE TAX RETURN. THE MEDICAL CENTER FOLLOWS GUIDANCE IN THE INCOME TAX STANDARD REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE MEDICAL CENTER FOLLOWS THE ACCOUNTING STANDARD FOR INCOME TAXES FOR EVALUATING UNCERTAIN TAX POSITIONS. PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS -3,471,555. INCOME STATEMENT ELIMINATIONS 25,597. PART XI, LINE 4B - OTHER ADJUSTMENTS: INVESTMENT INCOME -89,010. LOSS ON SALE OF ASSETS -35,924. COST OF GOODS SOLD -45,362. OTHER INCOME 282,168. INCOME STATEMENT ELIMINATIONS -22,800. PART XII, LINE 2D - OTHER ADJUSTMENTS: COST OF GOODS SOLD 45,362. INCOME STATEMENT ELIMINATIONS 48,397. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT 3,471,555. 1 1 X 1 X 1 X 1 1 0 1 1 527081 527081 0.00630 9783876 8014011 1769865 0.02110 10310957 8014011 2296946 0.02740 92691 92691 0.00110 92691 92691 0.00110 10403648 8014011 2389637 0.02850 1 46 10287 10287 0.00010 47 10287 10287 0.00010 1 3329799 1745402 23662733 24131411 -468678 X 1 1 1 1 ST CROIX REGIONAL MEDICAL CENTER 235 STATE STREET ST CROIX FALLS WI 54024 WWW.SCRMC.ORG 1043240922 X X X X ST CROIX REGIONAL MEDICAL CENTER 1 0 0 1 X X X X X X X X X 15 1 1 1 1 X HTTP://SCRMC.ORG/WP-CONTENT/UPLOADS/2015/08/CHA-2016.PDF X HTTP://HEALTHYPOLKCOUNTY.COM/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ X 1 15 0 1 0 1 X 100.000000000000 250.000000000000 X X X X 1 1 X X X 1 X HTTP://SCRMC.ORG/WP-CONTENT/UPLOADS/2016/03/FAP-POLICY-AND-APPENDIX.PDF X HTTP://SCRMC.ORG/WP-CONTENT/UPLOADS/2016/03/FINANCIAL-ASSISTANCE-APPLICATIO X HTTP://SCRMC.ORG/WP-CONTENT/UPLOADS/2016/03/PLAIN-LANGUGAE-SUMMARY-FINAL.PD X X X X X 1 X 0 X X X X 1 X 0 0 ST. CROIX REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 5: IN THE COLLECTION OF DATA FOR THE COMMUNITY HEALTH NEEDS ASSESSMENT, THE MEDICAL CENTER UTILIZED HEALTH AND LIFESTYLE COMMUNITY SURVEYS. A COUNTY WIDE SURVEY OF THE HEALTH OF POLK COUNTY RESIDENTS WAS MADE AVAILABLE TO THE PUBLIC TO PARTICIPATE. THIS SURVEY WAS MADE AVAILABLE AT ALL OF THE LOCAL MEDICAL CENTERS AND THE HEALTH DEPARTMENT AS WELL AS ADVERTISED IN THE LOCAL NEWSPAPERS AND POSTED ON ALL FOUR OF THE PARTNER'S ORGANIZATION'S WEBSITES. ONCE THE DATA WAS COLLECTED FROM THE SURVEYS, FOUR COMMUNITY FORUMS WERE SPONSORED IN BALSAM LAKE, ST. CROIX FALLS, AMERY AND OSCEOLA. THE COMMUNITY MEMBERS IN ATTENDANCE OFFERED INPUT AND SUGGESTIONS ON THE HEALTH FOCUS AREAS. IN ADDITION, A PARTNER MEETING WAS HELD TARGETING KEY ORGANIZATIONS AS WELL AS LOCAL HEALTH-RELATED COALITIONS. AT EACH OF THESE VENUES, ATTENDEES HAD THE OPPORTUNITY TO PROVIDE INPUT ON THE 10 HEALTH FOCUS AREAS AS WELL AS VOTE FOR THEIR TOP FIVE. ON APRIL, 12, 2016, A PARTNER MEETING CONVENED AND PARTICIPATED IN A PROCESS FOCUSING ON REVIEW AND DISCUSSION OF COMPILED DATA ON THE CURRENT HEALTH STATUS OF POLK COUNTY CITIZENS, AS WELL AS VOTING RESULTS FROM THE COMMUNITY FORUMS. DURING THIS MEETING, THIS GROUP COMPLETED A PAPER SURVEY TO CAST THEIR VOTES TO DETERMINE THE TOP FOUR HEALTH FOCUS AREAS FOR POLK COUNTY, WI. THE COLLABORATIVE GROUP OF THE POLK COUNTY HEALTH DEPARTMENT, THE THREE MEDICAL CENTERS AND MANY OTHER COMMUNITY ORGANIZATIONS ENGAGES COMMUNITY MEMBERS AND WORKS COLLECTIVELY WITH PARTNERS TO IMPROVE THE HEALTH OF THE COMMUNITY THROUGH ASSESSMENT, PRIORITIZATION, EFFECTIVE PLANNING, COLLABORATIVE IMPLEMENTATION AND EVALUATION. ST. CROIX REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 6A: THE MEDICAL CENTER WORKED IN COLLOBORATION WITH THE POLK COUNTY HEALTH DEPARTMENT, AMERY HOSPITAL AND CLINIC AND OSCEOLA MEDICAL CENTER WITH THE ULTIMATE GOAL TO IDENTIFY PRIORITY HEALTH ISSUES AND TO DEVELOP STRATEGIES TO ADDRESS THE COMMUNITY'S HEALTH NEEDS. ST. CROIX REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 6B: AS STATED ABOVE, SCRMC WORKED IN COLLABORATION WITH THE POLK COUNTY HEALTH DEPARTMENT FOR THEIR COMMUNITY HEALTH NEEDS ASSESSMENT. ST. CROIX REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 11: THE COMMUNITY MEMBERS IN ATTENDANCE OFFERED INPUT AND SUGGESTIONS ON THE HEALTH FOCUS AREAS. AT EACH OF THESE VENUES, ATTENDEES HAD THE OPPORTUNITY TO PROVIDE INPUT ON THE TOP HEALTH FOCUS AREAS. THE FINAL TOP HEALTH FOCUS AREAS SELECTED WERE 1) MENTAL HEALTH 2) SUBSTANCE ABUSE 3) ACCESS TO CARE AND 4) OBESITY. AFTER REVIEWING THE DATA, AND MAPPING EXISTING RESOURCES, SCRMC DEVELOPED AN IMPLEMENTATION STRATEGY. THE SCRMC GOVERNING BOARD APPROVED THE IMPLEMENTATION STRATEGY ON OCTOBER 25TH, 2016. THE ABOVE NEEDS WERE PRIORITIZED BASED ON SIZE, SEVERITY, AVAILABLE DATA, AND THE HOSPITAL'S ABILITY TO HAVE AN IMPACT. IN ORDER TO ADDRESS PRIORITY NEEDS, SCRMC WILL ENGAGE KEY COMMUNITY PARTNERS IN IMPLEMENTING STRATEGIES ACROSS THE SERVICE AREA. THESE STRATEGIES INCLUDE MODIFYING POLICES, PROVIDING SUPPORT, ENHANCING ACCESS, CHANGING CONSEQUENCES AND INCENTIVES, PROVIDING INFORMATION, AND ENHANCING SKILLS. SCRMC WORKS COLLABORATIVELY WITH OSCEOLA MEDICAL CENTER, AMERY MEDICAL CENTER, THE POLK COUNTY HEALTH DEPARTMENT, AND OTHER COMMUNITY MEMBERS TO DETERMINE THE FOUR MOST SIGNIFICANT HEALTH NEEDS OF THE COMMUNITY. SCRMC WOULD ALSO LIKE TO CONTRIBUTE EFFORTS TO OTHER COMMUNITY HEALTH NEEDS IDENTIFIED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT. - NUTRITION - NUTRITION NOW FALLS UNDER OBESITY. BECAUSE OBESITY WAS RANKED AS ONE OF THE MOST IMPORTANT HEALTH NEEDS, NUTRITION WILL BE ADDRESSED INDIRECTLY THROUGH MANY OF THE STRATEGIES AND ACTIVITIES AIMED AT REDUCING OBESITY. - PHYSICAL ACTIVITY - PHYSICAL ACTIVITY NOW FALLS UNDER OBESITY. BECAUSE OBESITY WAS RANKED AS ONE OF THE MOST IMPORTANT HEALTH NEEDS, PHYSICAL ACTIVITY WILL BE ADDRESSED INDIRECTLY THROUGH MANY OF THE STRATEGIES AND ACTIVITIES AIMED AT REDUCING OBESITY. - REPRODUCTIVE AND SEXUAL HEALTH - THOUGH NOT VOTED AS ONE OF THE TOP SIGNIFICANT HEALTH NEEDS OF POLK COUNTY, SCRMC IS COMMITTED TO PLAYING AN ACTIVE ROLE IN REPRODUCTIVE AND SEXUAL HEALTH. SCRMC IS, CURRENTLY, WORKING TOWARD RE-DESIGNING PATIENT EDUCATION MATERIALS TO BETTER SUIT PATIENT UNDERSTANDING. IF A PATIENT IS DEEMED SEXUALLY ACTIVE AND IS BETWEEN THE AGE OF 16-24, ALL PRIMARY CARE PROVIDERS SCREEN THE PATIENT FOR CHLAMYDIA AND GONORRHEA. FOR ALL TEEN PRIMARY CARE VISITS, "TEEN HEALTH" INFORMATION IS INCLUDED IN THE AFTER VISIT SUMMARY FOR THE PATIENT. DURING A PATIENT VISIT IN PRIMARY CARE, COUNSELING IS OFFERED FOR ANY ISSUE IN REPRODUCTIVE AND SEXUAL HEALTH.SCRMC ACKNOWLEDGES THE WIDE RANGE OF SIGNIFICANT HEALTH ISSUES THAT EMERGED FROM THE CHNA PROCESS, AND DETERMINED THAT IT COULD EFFECTIVELY FOCUS ON ONLY THOSE HEALTH NEEDS WHICH IT DEEMED MOST PRESSING, UNDER-ADDRESSED, AND WITHIN ITS ABILITY TO INFLUENCE. SCRMC WILL NOT TAKE NEW OR ADDITIONAL ACTIONS ON THE FOLLOWING HEALTH NEEDS AT THIS TIME: - UNINTENTIONAL INJURY - BECAUSE SUBSTANCE ABUSE WAS RANKED AS ONE OF THE MOST IMPORTANT HEALTH NEEDS, UNINTENTIONAL INJURY WILL BE ADDRESSED INDIRECTLY THROUGH MANY OF THE STRATEGIES AND ACTIVITIES AIMED AT REDUCING SUBSTANCE ABUSE. - DENTAL HEALTH SERVICES AND ORAL HEALTH -MANY OF THE KEY STAKEHOLDERS REPORTED ACCESS TO AFFORDABLE DENTAL CARE AS A NEED AMONG THE LOW-INCOME AND MEDICALLY UNDERSERVED POPULATIONS. SCRMC PROVIDERS PROMOTE THE POSITIVE HEALTH BENEFITS OF GOOD ORAL HEALTH AT PATIENT VISITS AND ALLOW DENTAL SERVICE PROMOTION AT SUITABLE SCRMC SPONSORED COMMUNITY AND EMPLOYEE EVENTS THROUGHOUT THE YEAR. DUE TO LIMITED RESOURCES AND SPACE, SCRMC IS UNABLE, AT THIS TIME, TO ADDRESS THE MATTER FURTHER. ST. CROIX REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 13H: SCRMC MAY PRESUMPTIVELY DETERMINE ELIGIBILITY OF PATIENTS BASED ON EXTERNAL SOURCES AND DATABASES WITHOUT A FAP-APPLICATION. ST. CROIX REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 22D: A PATIENT ELIGIBILE FOR FINANCIAL ASSISTANCE WILL NOT BE CHARGED MORE THAN AMOUNTS GENERALLY BILLED (AGB) BY ST. CROIX REGIONAL MEDICAL CENTER FOR EMERGENCY OR OTHER MEDICALLY NECESSARY CARE. CURRENTLY THE MEDICAL CENTER DETERMINES AGB BY MULTIPLYING GROSS CHARGES FOR ANY EMERGENCY OR OTHER MEDICALLY NECESSARY CARE PROVIDED TO A PATIENT ELIGIBLE FOR FINANCIAL ASSISTANCE BY AN AGB PERCENTAGE OF 46.7%, WHICH IS A 53.3% DISCOUNT. THE MEDICAL CENTER CALCULATED THIS PERCENTAGE BY DIVIDING THE SUM OF ALL ITS CLAIMS FOR MEDICALLY NECESSARY CARE ALLOWED BY HEALTH INSURERS DURING A PRIOR 12 MONTH PERIOD BY THE SUM OF THE ASSOCIATED GROSS CHARGES FOR THOSE CLAIMS. 5 1 - FREDERIC CLINIC 107 OAK STREET E FREDERIC WI 54837 PROVIDER BASED CLINIC 2 - INGALLS CLINIC 7456 MAIN STREET WEBSTER WI 54893 PROVIDER BASED CLINIC 3 - UNITY CLINIC 1482 190TH AVE BALSAM LAKE WI 54024 PROVIDER BASED CLINIC 4 - ST CROIX FALLS CLINIC 235 STATE STREET ST CROIX FALLS WI 54024 PROVIDER BASED CLINIC 5 - LINDSTROM CLINIC 12375 LINDSTROM LANE LINDSTROM MN 55045 FREE STANDING CLINIC PART I, LINE 3C: ST. CROIX REGIONAL MEDICAL CENTER, THROUGH ITS PATIENT ADVOCATES, EVALUATES EACH APPLICANT'S SITUATION IN ACCORDANCE WITH CRITERIA ESTABLISHED ANNUALLY BY THE BOARD OF DIRECTORS. THE CRITERIA INCLUDES: (1) INDIVIDUAL OR FAMILY INCOME (2) FAMILY SIZE (3) OTHER SOURCES OF PAYMENT FOR SERVICES. QUALIFICATION IS BASED ON ASSET LEVELS ESTABLISHED BY MEDICAL ASSISTANCE, FAMILY SIZE, AND INCOME LEVELS BASED ON 100% OF FEDERAL POVERTY GUIDELINES AS PUBLISHED ANNUALLY BY THE FEDERAL GOVERNMENT. IN ADDITION TO THE ABOVE LISTED ELIGIBILY REQUIREMENTS DEPENDENT UPON INCOME, SCRMC MAY ALSO PRESUMTIVELY DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE. PORTIONS OF OR THE ENTIRE FINANCIAL APPLICATION PROCESS MAY BE WAIVED FOR CERTAIN PATIENTS/GUARANTORS WHO PRESUMPTIVELY QUALIFY FOR FINANCIAL ASSISTANCE AND ARE SUBSEQUENTLY VERIFIED BASED ON SCRMC POLICIES AND PROCEDURES. EXAMPLES MAY INCLUDE PATIENTS/GUARANTORS WHO ARE HOMELESS, DECEASED WITHOUT AN ESTATE, BANKRUPTY, FOOD STAMPS AND/OR PATIENTS/GUARANTORS WHO QUALIFY BY EXTERNAL AVAILABLE DATA SOURCES SUCH AS CREDIT AGENCIES OR SOCIAL ECEONOMIC STATUS OF QUALIFYING FOR FINANCIAL ASSISTANCE. PART I, LINE 6A: ST. CROIX REGIONAL MEDICAL CENTER PARTICIPATES IN AN ANNUAL COMMUNITY BENEFIT REPORT PRODUCED BY THE WISCONSIN HOSPITAL ASSOCIATION. PART I, LINE 7: THE AMOUNTS INCLUDED IN PART I, LINE 7 WERE DERIVED USING THE COST-TO-CHARGE RATIO FROM WORKSHEET 2 OF THE IRS SCHEDULE H INSTRUCTIONS. PART I, LN 7 COL(F): BAD DEBT EXPENSES OF $3,329,799 WERE SUBTRACTED FROM TOTAL EXPENSES IN CALCULATING THE PERCENTAGES IN PART I, LINE 7, COLUMN F. PART II, COMMUNITY BUILDING ACTIVITIES: THE ORGANIZATION PROVIDES DIRECT SUPPORT TO OVER 47 COMMUNITY ACTIVITIES, PROVIDES OVER 19,000 HOURS OF VOLUNTEER TIME IN INDIRECT PATIENT CARE ACTIVITIES, AND OVER 400 HOURS OF EDUCATION FOR HEALTHCARE PROFESSIONALS. PART III, LINE 2: PATIENTS ARE NOT REQUIRED TO PROVIDE COLLATERAL FOR SERVICES RENDERED. PAYMENT FOR SERVICES IS REQUIRED UPON RECEIPT OF AN INVOICE, AFTER PAYMENT OF INSURANCE, IF ANY. SELF-PAY ACCOUNTS ARE ANALYZED FOR COLLECTIBILITY BASED ON THE MONTHS PAST DUE AND PAYMENT HISTORY. AN ALLOWANCE IS ESTIMATED FOR THESE ACCOUNTS BASED ON THE HISTORICAL EXPERIENCE OF THE MEDICAL CENTER. ACCOUNTS THAT ARE DETERMINED TO BE UNCOLLECTIBLE ARE SENT TO A COLLECTION AGENCY AND WRITTEN OFF AT THAT TIME. PART III, LINE 3: THE AMOUNT OF BAD DEBT EXPENSE ESTIMATED BY THE ORGANIZATION TO BE ATTRIBUTABLE TO PATIENTS ELIGIBLE FOR CHARITY CARE ON PART III, LINE 3 WAS DERIVED BY TAKING THE COST TO CHARGE RATIO AGAINST TOTAL BAD DEBT EXPENSES INCLUDED IN LINE 2. PART III, LINE 4: SEE THE "PATIENT ACCOUNTS RECEIVABLE AND ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS" SECTION IN NOTE 1 (PAGE 10) TO THE FINANCIAL STATEMENTS FOR INFORMATION ABOUT THE CALCULATION OF BAD DEBTS. PART III, LINE 8: THE MEDICAL CENTER PROVIDES MEDICAL CARE TO INDIVIDUALS WHERE GOVERNMENT DEPARTMENTS DETERMINE THE AMOUNT OF REIMBURSEMENT OF SERVICE REGARDLESS OF THE COST TO PROVIDE THE SERVICE. AMOUNTS REIMBURSED BY GOVERNMENT PAYORS ARE ESTIMATED TO BE LESS THAN THE COSTS TO PROVIDE THE SERVICES AS FOLLOWS:MEDICAID- WISCONSIN $2,523,000 CHAMPUS AND VA $62,500MEDICARE - PHYSICIAN $4,222,800MEDICARE ADVANTAGE $4,888,200ALL GOVERNMENT PAYORS $7,696,500TOTAL CHARITY CARE, UNCOMPENSATED CARE AND UNDER COMPENSATED CARE BY GOVERNMENT PAYORS WAS $4,640,055 THIS REPRESENTS 7.1% OF NET OPERATING REVENUES OF THE MEDICAL CENTER.THE MEDICARE ALLOWABLE COSTS INCLUDED IN PART III, LINE 6 WERE DERIVED USING THE FILED 2016 MEDICARE COST REPORT. PART III, LINE 9B: THE FOLLOWING PROCEDURES ARE SECTION 8 IN SCRMC'S BILLING AND COLLECTION POLICY INCLUDED ON THEIR WEBSITE AND DESCRIBES THE POLICY AND PROCEDURES USED FOR PATIENTS THAT MAY QUALIFY FOR FINANCIAL ASSISTANCE. ST. CROIX REGIONAL MEDICAL CENTER WILL MAKE REASONABLE EFFORTS TO PATIENT/GUARANTORS THAT FINANCIAL ASSISTANCE IS AVAILABLE, WHERE TO GET THE INFORMATION, HOW TO APPLY, AND ASSISTANCE AVAILABLE WITH APPLYING. ST. CROIX REGIONAL MEDICAL WILL ALLOW AND PROCESS A FINANCIAL ASSISTANCE APPLICATION UP TO 240 DAYS AFTER THE PATIENT/GUARANTOR'S FIRST BILLING STATEMENT AFTER A DATE OF SERVICE. ST. CROIX REGIONAL MEDICAL CENTER WILL TAKE STEPS TO NOTIFY PATIENT/GUARANTOR ABOUT OUR FINANCIAL ASSISTANCE POLICY AND WILL NOT TAKE EXTRAORDINARY COLLECTION ACTIONS BEFORE 120 DAYS FROM PATIENT/GUARANTOR'S FIRST BILLING STATEMENT AFTER A DATE OF SERVICE.IF A FINANCIAL ASSISTANCE APPLICATION IS RECEIVED DURING THE APPLICATION PERIOD, ST. CROIX REGIONAL MEDICAL CENTER WILL SUSPEND ANY EXTRAORDINARY COLLECTION ACTIONS TO OBTAIN PAYMENT, MAKE AN ELIGIBILITY DETERMINATION AS TO WHETHER THE PATIENT/GUARANTOR IS ELIGIBLE FOR FINANCIAL ASSISTANCE AND NOTIFY THE PATIENT/GUARANTOR IN WRITING. IF ELIGIBLE, THE FINAL NOTIFICATION PERIOD WILL BE RE-SET FOR ANOTHER 30 DAY PERIOD. IF A PATIENT/GUARANTOR DOES NOT APPLY FOR FINANCIAL ASSISTANCE UNDER THE FINANCIAL ASSISTANCE POLICY BY THE LAST DAY OF THE FINAL NOTIFICATION PERIOD, AND THE PATIENT/GUARANTOR HAS RECEIVED THE 30 DAY NOTICE DESCRIBED IN FINAL NOTIFICATION PERIOD, THEN ST. CROIX REGIONAL MEDICAL CENTER MAY INITIATE EXTRAORDINARY COLLECTION ACTIONS. IF A PATIENT/GUARANTOR HAS APPLIED FOR FINANCIAL ASSISTANCE UNDER THE FINANCIAL ASSISTANCE POLICY IN THE LAST SIX MONTHS, AND IT WAS DETERMINED THAT THE PATIENT/GUARANTOR IS NOT ELIGIBLE FOR FINANCIAL ASSISTANCE UNDER THE FINANCIAL ASSISTANCE POLICY, THEN SCRMC MAY INITIATE EXTRAORDINARY COLLECTION ACTIONS.IF AN INCOMPLETE FINANCIAL ASSISTANCE APPLICATION UNDER THE FINANCIAL ASSISTANCE POLICY IS RECEIVED PRIOR TO THE FINAL NOTICE, THEN EXTRAORDINARY COLLECTION ACTIONS WILL BE SUSPENDED AND PATIENT/GUARANTOR WILL BE PROVIDED A WRITTEN NOTICE THAT DESCRIBES ADDITIONAL INFORMATION REQUIRED UNDER THE FINANCIAL ASSISTANCE POLICY. IF ADDITIONAL INFORMATION REQUESTED IS NOT PROVIDED, THEN THE FINAL NOTIFICATION PERIOD WILL BE RE-SET. PART VI, LINE 2: OVERALL MARKETPLACE DEMOGRAPHICS AND COMPETITIVE ANALYSIS IS CONDUCTED ON A REGULAR BASIS. WHEN DEMAND FOR NEW SERVICE LINES IS INTENSIFIED, THEY ARE ADDED SLOWLY UNTIL DEMAND CAPACITY REACH CRITICAL LEVELS. PART VI, LINE 3: ALL PATIENTS HAVE ACCESS TO WRITTEN MATERIALS AND PAMPHLETS AT OR NEAR THE POINT OF REGISTRATION. IN ADDITION, PATENTS HAVE ACCESS TO PATIENT ADVOCATES WITH FULL KNOWLEDGE OF RESOURSES AVAILABLE. PART VI, LINE 4: THE ORGANIZATION SERVES A GEOGRAPHIC AREA OF APPROXIMATELY 300 SQUARE MILES IN WESTERN WISCONSIN THAT INCLUDES THE TOWNS OF ST CROIX FALLS, BALSAM LAKE, LUCK, MILLTOWN, FREDERIC, AND GRANTSBURG IN WISCONSIN AND TAYLORS FALLS AND LINDSTROM IN EASTERN MINNESOTA. PART VI, LINE 6: THE CENTER IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. PART VI, LINE 7, REPORTS FILED WITH STATES WI 1 TUITION REIMBURSEMENT 10 10744 PART I, LINE 2: THE ORGANIZATION'S PROCEDURES INCLUDE SUBSTANTIATION OF EXPENSES, GRADES, TRANSCRIPTS AND RECEIPTS, AS WELL AS FOLLOW UP WITH COMMUNITY ORGANIZATIONS AND LEADERS. X X X X 0 1 0 0 0 1 0 0 0 DAVE DOBOSENSKI CEO 481060 0 42500 0 0 0 15300 0 27764 0 566624 0 0 0 JOHN TREMBLE CFO & VP 220559 0 5000 0 1440 0 11442 0 2882 0 241323 0 0 0 GURDESH BEDI PHYSICIAN OF SCRMC 773347 0 1000 0 1440 0 15300 0 1026 0 792113 0 0 0 STEPHEN DENNIS PHYSICIAN OF SCRMC 271645 0 0 0 0 0 15300 0 25417 0 312362 0 0 0 MUHAMMAD KHAN PHYSICIAN OF SCRMC 297937 0 0 0 0 0 3231 0 31214 0 332382 0 0 0 CLAUDIO NUNES PHYSICIAN OF SCRMC 364384 0 0 0 0 0 15300 0 41431 0 421115 0 0 0 MINGZHU XU PHYSICIAN OF SCRMC 270449 0 1000 0 0 0 15300 0 26292 0 313041 0 0 0 PART I, LINE 4B CONTRIBUTIONS TO A 457(F) SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN: JOHN TREMBLE - $23,394 DAVE DOBOSENSKI - $34,917 PART I, LINE 6 ANNUAL EMPLOYER CONTRIBUTIONS TO THE 457F PLAN ARE CONDITIONED UPON ATTAINING CERTAIN PRE-SET GOALS AND ARE CONTINGENT ON APPROVAL BY THE BOARD OF DIRECTORS. THE AWARD IS BASED ON TWO COMPONENTS - LONGEVITY AND PERFORMANCE. PERFORMANCE IS BASED ON MEETING 3 GOALS - NET REVENUE, NET MARGIN AND NET ASSETS. A POLK COUNTY 396005730 2006-05-11 13000000 REFUND SERIES 2000 BONDS, FACILITY CONSTRUCTION AND EQUIPMENT PURCHASES 0 0 0 B POLK COUNTY 396005730 2006-12-27 3683432 FACILITY CONSTRUCTION 0 0 0 A 10046012 13000000 13000000 2008 0 0 1 1 B 2461814 3683432 3683432 2008 0 0 1 1 A 0 0 0 0 0 0 1 B 0 0 0 0 0 0 1 A 0 0 1 0 0 0 0 0 1 B 0 0 1 0 0 0 0 0 1 A 0 B 0 FORM 990, PART VI, SECTION A, LINE 1 ST. CROIX REGIONAL MEDICAL CENTER HAS AN EXECUTIVE COMMITTEE WITH BROAD AUTHORITY TO ACT ON BEHALF OF ITS BOARD OF TRUSTEES. THE EXECUTIVE COMMITTEE INCLUDES THE CHAIR, VICE CHAIR, SECRETARY, TREASURER AND ONE OTHER TRUSTEE FROM THE BOARD OF TRUSTEES. THE EXECUTIVE COMMITTEE HAS POWER TO TRANSACT ALL REGULAR BUSINESS OF THE ORGANIZATION DURING THE PERIOD BETWEEN MEETINGS OF THE BOARD OF TRUSTEES, SUBJECT TO ANY PERIOD LIMITATION IMPOSED BY THE BOARD OF TRUSTEES AND WITH THE UNDERSTANDING THAT ALL MATTERS OF MAJOR IMPORTANCE WILL BE REFERRED TO THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 6 ST. CROIX REGIONAL MEDICAL CENTER HAS TWO CLASSES OF MEMBERS - SPONSORING MEMBERS AND PHYSICIAN ELECTORS. INDIVIDUALS AND CORPORATIONS MAY BECOME SPONSORING MEMBERS THROUGH DONATIONS OF A SPECIFIED AMOUNT TO THE MEDICAL CENTER. INDIVIDUALS MAY BECOME PHYSICIAN ELECTORS BY PROVIDING SERVICES AT ST. CROIX REGIONAL MEDICAL CENTER THROUGH SPECIFIED EMPLOYMENT CONDITIONS. FORM 990, PART VI, SECTION A, LINE 7A PHYSICIAN ELECTORS VOTE IN THE ELECTION OF FOUR PHYSICIAN TRUSTEES. SPONSORING MEMBERS VOTE IN THE ELECTION OF FIVE COMMUNITY TRUSTEES. FORM 990, PART VI, SECTION A, LINE 7B THE MEMBERS VOTE ON THE AUDITORS EMPLOYED TO AUDIT THE BOOKS OF THE MEDICAL CENTER AND TO PREPARE AN ANNUAL REPORT. AN OPS COUNCIL, CONSISTING OF FIVE INDIVIDUALS APPOINTED BY RIVER VALLEY MEDICAL CENTER, A RELATED ORGANIZATION, HAS SIGNIFICANT OVERSIGHT AUTHORITY AT THE MEDICAL CENTER. THE OPS COUNCIL'S AUTHORITY INCLUDES, BUT IS NOT LIMITED TO, REVIEW AND APPROVE OF ALL POLICIES AND PROCEDURES AS THEY RELATE TO MEDICAL OPERATIONS AND RECOMMENDATION OF THE ANNUAL CAPITAL AND OPERATING BUDGETS TO THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 WENT THROUGH THE FOLLOWING REVIEW PROCESS BEFORE FILING WITH THE IRS: A DETAILED REVIEW WAS CONDUCTED BY THE ORGANIZATION'S INTERIM CFO, UPON APPROVAL, THE FORM 990 WAS THEN ELECTRONICALLY PROVIDED FOR REVIEW AND APPROVAL TO THE ORGANIZATION'S BOARD OF DIRECTORS IN MAY, 2017. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERSHIP IS CONTINGENT UPON ANNUAL DISCOSURE OF POTENTIAL AND ACTUAL CONFLICTS OF INTEREST. THE DERTERMINATION IS MADE AT THE BOARD LEVEL AND ALL BOARD MEMBERS MUST CERTIFY ANNUALLY. IF A BOARD MEMBER HAS A CONFLICT, THEY REFRAIN FROM VOTING OR PARTICIPATING IN DISCUSSIONS CONCERNING THAT TOPIC. FORM 990, PART VI, SECTION B, LINE 15A CEO - ANNUAL PERFORMANCE AND SALARY REVIEW IS CONDUCTED BY THE BOARD OF DIRECTORS USING SUCH OUTSIDE INFORMATION AS DEEMED NECESSARY. REVIEWS ARE CONDUCTED EACH JUNE. THE PROCESS LAST INCLUDED REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA AND CONTEMPORANEOUS SUBSTANTIATION IN 2016. OTHER OFFICERS - THE HUMAN RESOURCE DEPARTMENT CONDUCTS OUTSIDE RESEARCH TO DETERMINE REASONABLE COMPENSATION. THE CEO THEN DETERMINES THE COMPENSATION OF THESE INDIVIDUALS. REVIEWS ARE CONDUCTED EACH JUNE. THIS PROCESS LAST OCCURED IN FISCAL YEAR 2016. FORM 990, PART VI, SECTION C, LINE 19 THE MEDICAL CENTER'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC. FORM 990, PART IX, LINE 11G PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 11,927,629. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 11,927,629. THERAPIST & OTHER PHYS FEES: PROGRAM SERVICE EXPENSES 63,885. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 63,885. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 3,933,154. MANAGEMENT AND GENERAL EXPENSES 294,468. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,227,622. CONSULTING SERVICES: PROGRAM SERVICE EXPENSES 576,764. MANAGEMENT AND GENERAL EXPENSES 532,509. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,109,273. INDEPENDENT CONTRACTORS: PROGRAM SERVICE EXPENSES 1,126,299. MANAGEMENT AND GENERAL EXPENSES -12,553. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,113,746. SCHEDULE L, PART IV AND SCHEDULE R, PART V, LINE 1O ST. CROIX REGIONAL MEDICAL CENTER REIMBURSES RIVER VALLEY MEDICAL CENTER (RVMC), FOR PHYSICIAN SERVICES PROVIDED BY EMPLOYEES OF RVMC. ALL PAYMENTS ARE "GROSS", MEANING THAT THEY INCLUDE UNIDENTIFIED AMOUNTS FOR BENEFITS AND MALPRACTICE INSURANCE, AS WELL AS W-2 COMPENSATION. UNITY PHARMACY LLC 1504 190TH AVENUE SUITE 100 BALSAM LAKE WI 54810 454471131 PHARMACEUTICALS WI 1373748 431197 SCV PHARMACIES FREDERIC PHARMACY LLC 201 OAK STREET WEST FREDERIC WI 54837 464469897 PHARMACEUTICALS WI 2581804 1021291 SCV PHARMACIES ST CROIX VALLEY PHARMACY LLC 235 STATE STREET ST CROIX FALLS WI 54024 464463191 PHARMACEUTICALS WI 17 9267 ST CROIX REGIONAL MEDICAL CENTER ST CROIX FALLS PHARMACY LLC 216 SOUTH ADAMS STREET ST CROIX FALLS WI 54024 464487348 PHARMACEUTICALS WI 1744878 375684 SCV PHARMACIES ST CROIX VALLEY EMERGENCY MEDICAL SERVICES INC 235 EAST STATE STREET ST CROIX FALLS WI 54024 452872803 TO LEASE, MAINTAIN, AND OPERATE AN EMERGENCY AMBULANCE SERVICE. WI 501(C)(3) LINE 9 ST CROIX REGIONAL MEDICAL CENTER 1 CANCER CENTER OF WESTERN WISCONSIN 501 HOSPITAL ROAD NEW RICHMOND WI 54017 273238660 TO PROVIDE CARE TO CANCER PATIENTS. WI 501(C)(3) LINE 11A, I N/A 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0