2017-05-12T11:27:22-05:00 2016-06-30 550486667 Arnett Carbis Toothman LLP P O Box 2629 Charleston WV 25329 990 2015-07-01 550477361 Boone Memorial Hospital Inc BOON 3043691230 701 Madison Avenue Madison WV 25130 Randell Foxx CFO 3043691230 2017-05-11 1 Tessa W Carr P01291277 3043460441 2015 2021-01-29 14:40:06Z Virgil Underwood 701 Madison Avenue Madison WV 25130 28645835 0 X www.bmh.org X 2010 WV Boone Memorial hospital strives to supply a comprehensive range of inpatient and outpatient services, including prevention, guidance, diagnosis, treatment, restoration, rehabilitation and other efforts to enable patients to lead healthy, productive lives, as may be needed by its community, and as its resources will permit. In carrying out its programs, Boone Memorial Hospital recognizes its responsibility to make services available to all persons who can benefit from them and to provide these in an economical manner in compliance with high professional standards. The hospital further recognizes responsibility to develop an organizational environment in which physicians, employees, volunteers and other individuals constituting its staff are stimulated to high standards of performance and can find maximum satisfaction, achievement and opportunity. As an equal opportunity employer it will not permit discrimination because of race, color, religion, sex, age, national origin or handicap. 8 8 228 40 0 0 480271 664861 27143518 27436501 102551 180906 713167 342299 28439507 28624567 45097 53417 0 0 10544537 11521189 50051 0 21044 16250120 15704957 26889805 27279563 1549702 1345004 26881258 48592181 18315928 38681847 8565330 9910334 X The basic mission of Boone Memorial Hospital is to create an environment in which qualified physicians and other health care personnel can work together to provide high quality health care service, in an atmosphere of brotherly love and concern, to the residents of Boone County and surrounding areas. 0 0 22073578 27744482 In performing its mission, Boone Memorial Hospital had 413 acute care admissions and 113 skilled nursing care admissions. The Hospital also had 3 respite care patients, 12,350 emergency room visits, 20,057 out-patient visits and 24,535 visits in its two rural health clinics. 15202 15998 Boone Memorial Hospital conducts an annual health fair. The Hospital uses the local Madison Civic Center and offers very low cost blood work to the community. Approximately 475 community members attended the health fair and approximately 182 received low cost blood work. 125860 34998 BMH Respite Care Program. The Hospital had 3 respite care admissions and 12 respite days for its 6/30/16 fiscal year. The respite care program is a cash only program. It is not billed to insurance, but the rate is only $116 per day. We offer this as a community benefit. 53417 53417 The hospital provided 7 student loan forgiveness grants during the year. 53417 53417 22268057 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 52 0 228 1 0 0 0 0 0 1 1 0 0 0 0 X 8 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 WV X Randell D Foxx 3043691230 701 Madison Avenue Madison WV 25130 Robert Brown President 1.30 X X 0 0 0 James Hensley Vice President 1.30 X X 0 0 0 Thomas Bias Secretary 1.30 X X 0 0 0 Douglas Bell Board Member 1.30 X 0 0 0 William Stone Board Member 1.30 X 0 0 0 Shawn Miller Board Member 1.30 X 0 0 0 James Gore Board Member 1.30 X 0 0 0 Nada Woodie Board Member 1.30 X 0 0 0 Virgil Underwood CEO as of 2/2015 40.00 X 157704 0 11109 Randell D Foxx CFO, Interim Co-CEO until 2/2015 40.00 X 169414 0 17736 Mark Linville COO, Interim Co-CEO until 2/2015 40.00 X 126250 0 15955 Ziad Chanaa Physician 21.00 X 141320 0 80561 Kevin Hill PA 47.00 X 183686 0 18149 Tarah Hager PA 45.00 X 132445 0 10205 David Gresham CDO 40.00 X 130000 0 0 Kristina Stover PA 44.00 X 113535 0 7636 1154354 0 161351 13 0 1 0 Neighborgall Construction Co 1216 Seventh Avenue Huntington WV 25701 General Contractor-New Hospital 10463059 Rehab One Ltd 1834 Park Avenue Belle WV 25015 Physical Therapy Services 1049500 CPSI PO Box 850309 Mobile AL 36685 System Software Vendor 1022791 Cherry River Construction LLC 85 Legacy Ridge Red House WV 25168 General Contractor-New Hospital 806388 Pharmacy Management and Consulting Servi 928 Helene Street St Albans WV 25177 Pharmacy Management 659602 21 55811 609050 664861 Patient Service Revenue 622110 26198089 26198089 340B Program Revenue 900099 1238412 1238412 27436501 180906 180906 50 0 50 50 50 4540 55811 21268 -16728 -16728 Pharmacy 446110 114093 114093 EHR Incentive Revenue 900099 96000 96000 Dietary Sales 900099 80803 80803 68081 68081 358977 28624567 27795478 0 164228 X 53417 53417 340913 245355 95558 8419071 6059205 2359866 117824 84798 33026 1982905 1427097 555808 660476 475345 185131 52934 52934 143201 143201 8119609 7683527 436082 147977 147977 2012281 1448239 564042 42766 30779 11987 242578 174583 67995 12035 8662 3373 38489 27701 10788 1703 1226 477 354919 255435 99484 418863 301456 117407 Medical supplies 1744546 1744546 Bad debt expense 1072618 1072618 Provider tax 663643 663643 Charity Care Expense 238687 238687 398108 271738 105326 21044 27279563 22268057 4990462 21044 5714898 3036781 1348912 6043822 9360 2830681 2797384 61929 27775 310245 430546 144502 107256 38088609 2447357 15088363 35641252 191255 1181113 507365 26881258 48592181 5569688 5866777 383595 96000 8835974 29321918 3526671 3397152 18315928 38681847 X 8160858 8843961 404472 1066373 8565330 9910334 26881258 48592181 1345004 0 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 404472 661901 1066373 404472 404472 1.00000 0 0 216178 216178 27948497 421500 27526997 6633551 2025857 4607694 3290383 3290383 35641252 Third Party Payor Settlements 3205949 Deferred revenue, net of current portion 191203 3397152 27334530 21268 21268 27313262 1311305 1311305 28624567 25989526 21268 21268 25968258 1311305 1311305 27279563 Part V, Line 4: The funds are to be used for capital improvements. Part XI, Line 2d - Other Adjustments: Direct fundraising expense netted against fundraising income 21,268. Part XI, Line 4b - Other Adjustments: Bad debt expense netted with revenue on financial statements 1,072,618. Charity care expense netted with revenue on financial statements 238,687. Part XII, Line 2d - Other Adjustments: Direct fundraising expense netted against fundraising income 21,268. Part XII, Line 4b - Other Adjustments: Bad debt expense netted with revenue on financial statements 1,072,618. Charity care expense netted with revenue on financial statements 238,687. Golf Tournament 57611 55811 1800 5000 1006 6711 8551 2016 5k Run 2740 2740 60351 55811 4540 5000 1006 6711 8551 21268 -16728 1 1 X 1 X 1 X 240.000000000000 1 1 0 0 84526 84526 7819012 7819012 7903538 7903538 141062 50996 90066 0.00340 141062 50996 90066 0.00340 8044600 7954534 90066 0.00340 1 379847 5083208 5083208 X 1 1 1 1 Boone Memorial Hospital Inc 701 Madison Avenue Madison WV 25130 www.bmh.org X X X X Two rural health clinics, SNF/NF beds Boone Memorial Hospital Inc 1 0 0 1 X X X X X X X X 15 1 0 0 1 X http://media.wix.com/ugd/3f447f_3fce1182086a48f7bc4b2649bdd7e2ca.pdf X 1 15 1 http://media.wix.com/ugd/3f447f_3fce1182086a48f7bc4b2649bdd7e2ca.pdf 0 0 1 X 100.000000000000 240.000000000000 X X X X 1 1 X X X 1 X http://media.wix.com/ugd/3f447f_7f16f4d8221b4aeb80861e83adf1f875.pdf X http://media.wix.com/ugd/3f447f_f78c6d10ee0d43d8915549467626c606.pdf X http://media.wix.com/ugd/3f447f_d54b7cf9599d4b35b28620aa527b698f.pdf X X X X X 1 X 0 X X X 1 X 0 0 Boone Memorial Hospital, Inc. Part V, Section B, Line 5: Assembled an Advisory Panel comprised of representatives from community leaders, health care providers, and local citizens to assist with the assessment process. Boone Memorial Hospital, Inc. Part V, Section B, Line 11: Boone Memorial Hospital developed an implementation plan that addressed the majority of the significant community needs identified in the CHNA. The areas addressed included alcohol and drug abuse, drunk driving and lack of recreational programs. The Hospital sponsored multiple community events/educational seminars that included health fairs, monthly diabetic educational classes, drug and alcohol abuse prevention forums and a low cost fitness center program for the community. As with most health care facilities, we have limited financial resources to address all issues. Boone Memorial Hospital, Inc. Part V, Section B, Line 16i: MEASURES TO PUBLICIZE THE FINANCIAL ASSISTANCE POLICYThe following measures are used to publicize the financial assistance available from BMH to the community and patients in accordance with Federal and State law: a. Providing information when a patient calls BMH at (304) 369-1230;b. Annually posting an article in a newspaper of local circulation and/or other means as deemed reasonably necessary;d. Posting of a notice in the emergency department admitting areas and business offices at BMH; and/ore. Financial Counselors visiting with BMH inpatients. Boone Memorial Hospital, Inc. Part V, Section B, Line 22d: FAP eligible individuals are billed using the gross charges method. The gross charges are stated on the billing statement reduced by average contractual allowances; eligible discounts; and other deductions. Part I, Line 3c: Patients must provide their "Total Yearly Income" in order to be considered for financial assistance.a. Adults: If the patient is an adult, the term "Total Yearly Income" means the sum of the total yearly gross income of the patient and the patient's spouse.b. Minors: If the patient is a minor, the term "Total Yearly Income" means the sum of the total yearly gross income of the patient, the patient's mother and the patient's father.The patient, immediate family member or patient representative shall verify the patient's reported Total Yearly Income, as provided on the Application. The Total Yearly Income may be verified through any of the following mechanisms:a. Income Indicators. By the provision of third party financial documentation including IRS Form W-2, Wages and Tax Statement; pay check remittance; individual tax return; telephone verification by employer; bank statements; Social Security payment remittance; Worker's Compensation payment remittance; unemployment insurance payment notice; Unemployment Compensation Determination Letters; or other appropriate indicators of the patient's Total Yearly Income.b. Participation in a Benefit Program. By the provision of documentation showing current participation in a public benefit program such as Medicaid; Food Stamps; WIC; or other similar means tested programs. Proof of Participation in any of the above programs indicates that the patient has been deemed Financially Indigent and therefore, is not required to provide his or her income on the Assistance Application.c. In cases where the patient or responsible party is unable to provide third party verification of patient's Total Yearly Income, verification of the patient's Total Yearly Income can be done in either of the following ways:1. Obtaining the patient's or responsible party's Written Attestation. By obtaining an Application signed by the patient or responsible party attesting to the veracity of the patient's Total Yearly Income information provided: or2. Obtaining the patient's or responsible party's Verbal Attestation. Through the written attestation of the BMH employee completing the Assistance Application that the patient or responsible party verbally verified the patient's Total Yearly Income information provided.3. In instances where the patient or responsible party is unable to provide the requested third party verification of patient's Total Yearly Income, the patient or responsible party is required to provide a reasonable explanation of why the patient or responsible party is unable to provide the required third party verification. Sound business practices will be employed to verify patient's attestation and supporting information.Unmarried expired patients may be deemed to have no income for purposes of calculation of Total Yearly Income. Documentation of Total Yearly Income is not required for expired patients; however, documentation of estate assets may be required. If an expired patient is married, the surviving spouse may apply for financial assistance.Patients, immediate family members or patient representatives applying for financial assistance must verify the number of people in the patient's household ("Number in Household").a. Adults: In calculating the Number in Household, include the patient, the patient's spouse, and any dependents (as defined by the Internal Revenue Code).b. Minors: In calculating the Number in Household, include the patient, the patient's mother, the patient's father, dependents of the patient's mother, and dependents of the patient's father.During the verification process, while information to determine a patient's Total Yearly Income is being collected, the patient may be treated as a private pay patient. 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 $ 1,072,618. Part III, Line 2: The cost of bad debts was estimated using a cost to charge ratio derived from Worksheet 2 of the Schedule H instructions. Part III, Line 4: Patient accounts receivable are carried at the original charge less an estimate made for doubtful or uncollectible accounts. The allowance is based upon a review of the outstanding balances aged by financial class. Management uses collection percentages based upon historical collection experience to determine collectibility. Management also reviews troubled, aged accounts to determine collection potential. Patient accounts receivable are written off when deemed uncollectible. Recoveries of accounts previously written off are recorded as a reduction to bad debt expense when received. Interest is not charged on patient accounts receivable. Part III, Line 8: Medicare allowable costs were derived from the Medicare care cost report for the period ended 6/30/16. Part III, Line 9b: After the patient's account is reduced by the discounts based on the Financial Assistance Eligibility Discount Guidelines, the patient is responsible for the remainder of their outstanding account. Patients will be invoiced for any remaining amounts in accordance with other BMH Debt Collection Policies regarding this matter. Part VI, Line 2: The BMH project team completed the community needs assessment using the following strategies:-Assembled an Advisory Panel comprised of representatives from community including business leaders, health care providers, teachers, students and other local citizens to assist with the assessment process.-Conducted primary data collection through surveys of providers, key informants, and the general population. Phone interviews were also conducted as well as online survey requests.-Collected secondary data sources such as information from the US Census Data; state health statistics and behavioral risk assessments; and Centers for Disease Control statistics and data.-Held several focus groups to obtain a diverse range of responses in an open discussion format. Focus group 1 inlcuded medical and business professionals and Boone Memorial Hospital staff; Focus groups 2 and 3 included senior citizens from two county senior nutrition programs; and Focus group 4 included teens from the local 4-H Club. Part VI, Line 3: Measures to publicize the Financial Assistance Policy:The following measures are used to publicize the financial assistance available from BMH to the community and patients in accordance with Federal and State law: a. Posting on the BMH website at the following location: www.bmh.org; b. Providing information when a patient calls BMH at (304) 369-1230; c. Annually posting an article in a newspaper of local circulation and/or other means as deemed reasonably necessary; d. Posting of a notice in the emergency department admitting areas and business offices at BMH; and/or e. Financial Counselors visiting with BMH inpatients. Part VI, Line 4: BMH serves primarily Boone County, WV and portions of Logan and Lincoln Counties in WV. Boone County had an estimated population of 23,372 in 2015. The median household income was $41,359 with 18.9% below the federal poverty guideline; 17.4% of the population is over 65; 50.4% of the population is female; and 22.3% is below 18. Median household income in 2014 dollars was $42,740 and persons in poverty was 22.1%. Part VI, Line 5: Each member of the Board of Trustees is a local, lifelong Boone County resident. The ER is always available to all patients, regardless of ability to pay. Boone Memorial has made the most recent Community Needs Assessment report available on its website for all patients to have easy access to read. BMH offers patients access to our own MRI seven days a week instead of having to travel to other larger hospitals in Charleston or Logan. Most other Critical Access Hospitals in WV only offer a mobile MRI service one or two days a week. We have a fully digital radiology department with a PACS system. Our lab has just recently expanded to incorporate additional testing equipment. We also operate two RHCs with extended hours (one has Saturday hours) to help serve the community. 0 Student Loan Assistance 7 53417 Cash - FMV Student loan assistance to professional employees X 0 0 0 0 0 0 0 0 0 Virgil Underwood CEO as of 2/2015 153898 0 0 0 3806 0 0 0 12120 0 169824 0 0 0 Randell D Foxx CFO, Interim Co-CEO until 2/2015 163109 0 0 0 6305 0 6305 0 12585 0 188304 0 0 0 Ziad Chanaa Physician 141320 0 0 0 0 0 66000 0 14561 0 221881 0 0 0 Kevin Hill PA 174547 0 0 0 9139 0 3588 0 16839 0 204113 0 0 0 Form 990, Part VI, Section B, line 11 Randell Foxx, CFO will review the Form 990 for accuracy prior to filing with the IRS. A copy of the final Form 990 will be provided to the Board of Directors prior to filing with the IRS. Form 990, Part VI, Section B, line 12c Compliance is enforced and monitored when trustees recuse themselves on conflict of interest issues. Form 990, Part VI, Section B, line 15a An outside firm (Yaffe & Company) is consulted. The CEO presents recommendations to the board. The board will hold an executive session and decide the CEO's compensation. Form 990, Part VI, Section C, line 19 Financial statements are published annually in the local newspaper. The governing documents and conflict of interest policy are available upon request. Form 990, Part IX, line 11g Surgery: Program service expenses 555,075. Management and general expenses 0. Fundraising expenses 0. Total expenses 555,075. Radiology: Program service expenses 544,235. Management and general expenses 0. Fundraising expenses 0. Total expenses 544,235. Pharmacy: Program service expenses 660,487. Management and general expenses 0. Fundraising expenses 0. Total expenses 660,487. Physicians: Program service expenses 2,840,220. Management and general expenses 0. Fundraising expenses 0. Total expenses 2,840,220. Lab: Program service expenses 644,364. Management and general expenses 0. Fundraising expenses 0. Total expenses 644,364. Emergency room: Program service expenses 143,610. Management and general expenses 0. Fundraising expenses 0. Total expenses 143,610. Physical therapy: Program service expenses 1,175,849. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,175,849. Administrative: Program service expenses 745,791. Management and general expenses 290,461. Fundraising expenses 0. Total expenses 1,036,252. All other: Program service expenses 373,896. Management and general expenses 145,621. Fundraising expenses 0. Total expenses 519,517.