2016-11-14T16:20:04-06:00 2015-12-31 390758449 Wipfli LLP 3703 Oakwood Hills Pkwy Eau Claire WI 54701 990 2015-01-01 390806828 MEMORIAL HOSPITAL INC MEMO 7157433101 216 SUNSET PLACE NEILLSVILLE WI 54456 Ryan Neville CEO 7157433101 2016-11-14 1 DONNA NELSON CPA P00968978 7158323407 2016-11-14 2015 2017-02-10 21:41:12Z Ryan Neville 216 SUNSET PLACE NEILLSVILLE WI 54456 26952609 0 X WWW.MEMORIALMEDCENTER.ORG X 1954 WI MEMORIAL HOSPITAL, INC.'S MISSION IS TO PROVIDE THE COMMUNITIES WE SERVE THE BEST EXPERIENCE IN HEALTH CARE, EDUCATION, AND PREVENTION SUPPORTED BY OUR PILLARS OF PEOPLE, SERVICE, QUALITY AND SAFETY, FINANCE, COMMUNITY, AND GROWTH...ONE PATIENT AT A TIME. MEMORIAL HOSPITAL, INC. PROVIDES SERVICES THROUGH ITS 25-BED CRITICAL ACCESS HOSPITAL, ASSISTED LIVING, AS WELL AS 3 RURAL HEALTH CLINICS LOCATED IN NEILLSVILLE, LOYAL, AND GREENWOOD, WISCONSIN. TO FULFILL COMMUNITY NEEDS, MEMORIAL HOSPITAL, INC. FACILITATES EDUCATIONAL SEMINARS AND SUPPORT GROUPS LED BY MEDICAL AND PROFESSIONAL STAFF AT GREATLY REDUCED-RATES; PROVIDES FREE HEALTH SCREENINGS AT GIVEN TIMES THROUGHOUT THE YEAR; STAFF BOOTHS AT COMMUNITY EVENTS; SERVES AS AN EDUCATION SITE FOR STUDENTS IN HIGH SCHOOL, TECHNICAL COLLEGE, AND UNIVERSITIES; AS WELL AS OTHER NEEDS AS DETERMINED. MEMORIAL HOSPITAL, INC. ALSO ADMINISTERS A CHARITY CARE PROGRAM HELPING TO ENSURE AFFORDABLE ACCESS TO HEALTH CARE. 11 6 256 78 434593 -194364 142543 110899 24174112 26414056 87046 -71782 464289 404455 24867990 26857628 0 0 0 0 15109918 16419504 0 0 0 10423636 10103725 25533554 26523229 -665564 334399 15247440 15651312 5841327 5910800 9406113 9740512 X TO PROVIDE THE COMMUNITIES WE SERVE THE BEST EXPERIENCE IN HEALTH CARE, EDUCATION, AND PREVENTION, SUPPORTED BY OUR PILLARS OF PEOPLE, SERVICE, QUALITY AND SAFETY, FINANCE, COMMUNITY, AND GROWTH...ONE PATIENT AT A TIME. 0 0 14632376 22185303 MEMORIAL HOSPITAL, INC. (THE "HOSPITAL"), A 25-BED RURAL HOSPITAL, IS A NONPROFIT, NONSTOCK WISCONSIN CORPORATION PROVIDING SERVICES TO NEILLSVILLE, WISCONSIN, AND THE SURROUNDING COMMUNITIES. HOSPITAL INPATIENT SERVICES IN 2015 INCLUDED 727 ACUTE CARE PATIENT DAYS, 187 OBSERVATION DAYS, AND 530 SWING BED PATIENT DAYS.EMERGENCY ROOM VISITS TOTALED 530, URGENT CARE VISITS TOTALED 2,727, AND SURGERIES AND PROCEDURES TOTALED 848 IN 2015.OTHER HOSPITAL SERVICES PROVIDED IN 2015 INCLUDED BUT WERE NOT LIMITED TO: PRIMARY CARE, ORTHOPEDIC AND GENERAL SURGERY CLINIC AND PROCEDURES, ATHLETIC TRAINING, DIETARY, PAIN MANAGEMENT, PHARMACY, PHYSICAL THERAPY, RADIOLOGY, LABORATORY, CARDIAC REHABILITATION, RESPIRATORY THERAPY, OCCUPATIONAL THERAPY, AND DIABETIC EDUCATION. 6290671 3665445 Memorial Hospital, Inc. also owns and operates three clinics located in Neillsville, Loyal, and Greenwood, Wisconsin. Total clinic visits for 2015 was 23,403. 747461 381281 The assisted living facility is an alternative for seniors who can no longer live safely in their own home, yet do not need 24-hour medical supervision. Sunset Gardens is a housing and health care alternative, combining independence with personal care, in a warm, dignified, home-like atmosphere. Sunset gardens has 11 private rooms and 2 double rooms, for a couple or siblings. Meals, snacks, housekeeping, laundry, cable television, and maintenance services are provided. Social and recreational programs and a chapel are also provided. Health care services include a registered nurse on-site or on-call 24-hours per day, medication management, and personal care services provided by certified nursing assistants (such as assistance with bathing, dressing, and grooming). THE ASSISTED LIVING PROVIDED approximately 4,535 resident days during 2015. 21670508 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 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 1 1 0 0 0 1 43 0 256 1 1 1 0 0 0 0 0 0 0 0 0 X 11 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X Kelly Silbernagel 7157433101 216 SUNSET PLACE neillsville WI 54456 X ROBERT BARTH CHAIRMAN 2.00 0.50 X X 275 0 0 RICK SZYMANSKI BOARD MEMBER 1.00 X 325 0 0 Kevin Grap SECRETARY 1.00 X X 200 0 0 TREVOR WUETHRICH BOARD MEMBER 1.00 X 250 0 0 MARY KAY MILLS Board MEMBER 1.00 0.50 X 325 0 0 JAMES CHADWICK Board MEMBER 1.00 X 325 0 0 GARY WEIRAUCH Board MEMBER 1.00 X 300 0 0 RUSSELL RATSCH VICE CHAIRMAN 1.00 X X 275 0 0 BARBARA PETKOVSEK Board MEMBER 1.00 X 225 0 0 DR DAVID CARLSON CHief Medical Officer 33.00 X 791331 0 21027 DR SHARON HAYWARD PHYSICIAN 33.00 X 493102 0 31149 ROGER SNEATH INTERIM CFO 40.00 X 93229 0 0 RYAN NEVILLE PRESIDENT & CEO 40.00 0.50 X 228495 0 32220 Kelly Silbernagel CFO 40.00 X 96537 0 25518 DR MARIA CRUZ-APOLINARIO PHYSICIAN 33.00 X 667780 0 29379 DR Timothy Meyer PHYSICIAN 33.00 0.50 X 432191 0 13317 DR AMY SCHNEIDER DE CORTEZ PHYSICIAN 33.00 X 300270 0 24519 Dr James Stanga PHYSICIAN 33.00 X 297038 0 25254 Dr Kenneth Weimer PhYSICIAN 33.00 X 289776 0 31815 3692249 0 234198 19 0 1 0 EMCARE INC 8032 COLLECTION CENTER DRIVE CHICAGO IL 60693 ER Medical Services 571465 Wi ANETHESIA SERVICE LLC W5844 ROLLING HILL DRIVE NEILLSVILLE WI 54456 ANETHESIA SERVICES 457291 OS Inc W237N2920 Woodgate Suite 100 Pewaukee WI 53072 Patient Financial Services 403000 EvidentCPSI Inc PO Box 850309 Mobile AL 36685 ELECTRONIC Health Records Software 332388 Emile W Salvo MD SC 17312 Interlude Rd Tomah WI 54660 ER Medical Services 255726 8 76851 9178 24870 110899 Hospital Revenue 621110 22215441 22185303 30138 Clinic Revenue 621110 3665445 3665445 ASSISTED LIVING Revenue 623000 381281 381281 151889 151889 26414056 9940 9940 13259 94981 -81722 -81722 -81722 DIET,MAINT,HSKG,LNDRY 812900 404455 404455 404455 26857628 26232029 434593 80107 X 1815108 1336609 478499 10616970 8884588 1732382 304443 254767 49676 2968968 2502113 466855 714015 593742 120273 24326 24326 60431 60431 3501412 2701113 800299 75118 75118 818562 625215 193347 40838 40838 498398 323607 174791 67095 37866 29229 54081 34411 19670 1253508 813895 439613 179849 102965 76884 Medical Supplies 2103435 2103435 Equipment Rental & Main 679486 608996 70490 BAD DEBT 674199 674199 ADMIN HOSPITAL TAX EXPE 72987 72987 26523229 21670508 4852721 0 388985 1089525 1856313 1936379 2961357 3129727 652732 667823 209613 184043 17642028 11547371 6448078 6094657 2730362 2549158 15247440 15651312 3234967 3157681 1436609 1661963 1169751 1091156 5841327 5910800 X 9406113 9740512 9406113 9740512 15247440 15651312 334399 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 6390 6390 0 Part II-B, Line 1: Memorial Hospital, Inc. pays annual association membership dues to the Wisconsin Hospital Association (WHA) and American Hospital Association (AHA). These dues are primarily for access to educational materials and staff training and development. The WHA and AHA have notified Memorial Hospital, Inc. that $1,173 (WHA) and $1,654 (AHA) of the annual dues were used in conjunction with lobbying activities with the goal of improving the overall health care environment. Memorial Hospital, Inc. is also a member of the Rural Wisconsin Health Cooperative (RWHC). Each year, Memorial Hospital, Inc. pays membership fees to the RWHC. The 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 physician 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 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. The RWHC determined that $3,563 of the fees paid in 2015 related to lobbying activities with the goal of improving the health care environment in the state of Wisconsin. 15713 15713 10854267 7060185 3794082 6512784 4250214 2262570 259264 236972 22292 6094657 Investment in Central MN Diagnostic, Inc. 329026 Deferred compensation plan assets 1099899 amounts receivable from third-party reimbursement programs 504000 Other Receivables 616233 2549158 DEFERRED COMPENSATION LIABILITY 1091156 1091156 1 1 1 X 49.000000000000 1 X 1 1 0 1 1 68240 68240 0.00260 3710763 3189704 521059 0.01960 3779003 3189704 589299 0.02220 53945 4125 49820 0.00190 228752 228752 0.00860 9473110 4236841 5236269 0.19740 682 682 0.00000 5724 5724 0.00020 9762213 4240966 5521247 0.20810 13541216 7430670 6110546 0.23030 5472 5472 0.00020 256 256 0.00000 5728 5728 0.00020 0 409818 163927 4606601 4705939 -99338 X 1 1 1 1 Memorial Hospital Inc 216 Sunset Place Neillsville WI 54456 www.memorialmedcenter.org 1026 X X X X Memorial Hospital Inc 1 0 0 1 X X X X X X X X X 13 1 1 1 1 X www.memorialmedcenter.org X 1 13 1 http:/memorialmedcenter.org/wp-content/uploads/2016/07community-health-need 0 0 1 X 49.000000000000 300.000000000000 X X 1 1 X X X X 1 X www.memorialmedcenter.org X www.memorialmedcenter.org X X X 1 X 0 X X X X 1 X 0 0 Memorial Hospital, Inc. Part V, Section B, Line 5: Representatives from Memorial Hospital, Inc. and Ministry Our Lady of Victory Hospital partnered with the Clark County Public Health Department to establish the "Health Care Partnership for Clark County." In addition to the founding organizations, other participating members represent a variety of Clark County based organizations. The Partnership was awarded a grant to pilot community assessment tools that brought special public health expertise and knowledge to the process. Memorial Hospital, Inc. Part V, Section B, Line 6a: The CHNA was conducted in joint effort with Ministry Our Lady of Victory Hospital (Stanley, Wisconsin). Memorial Hospital, Inc. Part V, Section B, Line 6b: THE CHNA WAS CONDUCTED IN JOINT EFFORT WITH THE CLARK COUNTY PUBLIC HEALTH DEPARTMENT. Memorial Hospital, Inc. Part V, Section B, Line 11: THE FOLLOWING ITEMS WERE ITEMS IDENTIFIED IN THE CHNA FOR MEMORIAL HOSPITAL, INC. (THE "HOSPITAL") AND ARE BEING ADDRESSED AS FOLLOWS: CLARK COUNTY WISCONSIN, THROUGH ITS 2013-2015 COMMUNITY NEEDS ASSESSMENT IDENTIFIED THE FOLLOWING LOCAL HEALTH PRIORITIES- HEALTHY LIFESTYLE CHOICES TO INCLUDE PHYSICAL ACTIVITY AND HEALTHY EATING AND ACCESS TO INCLUDE MENTAL HEALTH/TRANSPORTATION AND PREVENTATIVE HEALTH SCREENINGS. MEMORIAL MEDICAL CENTER (MMC) CONTINUES TO ALIGN NOT ONLY ITS COMMUNITY VOLUNTEERISM BUT ALSO THE CURRENT STRATEGIC PLAN ACCORDING TO THE CLARK COUNTY COMMUNITY NEEDS. THE 4 KEY COMPONENTS OF MMC STRATEGIC PLAN ARE ACCESS TO CARE, COMMUNITY PARTNERSHIP, PROGRAMS DEVELOPED AND FINANCIAL STABILITY. CLARK COUNTY IDENTIFIED NEEDS AS FOLLOWS: 1) HEALTHY LIFESTYLE CHOICES-EMPHASIS ON PHYSICAL ACTIVITY AND HEALTHY EATINGA) MMC IS AN INFLUENTIAL LEADER IN THE COMMUNITY HEALTH IMPROVEMENT PLAN (CHIP) WHICH IN 2015 IDENTIFIED HEALTH PRIORITIES THROUGH THE COMMUNITY HEALTH IMPROVEMENT PROCESS.B) MMC ACTIVELY ATTENDED AND SUPPORTED THE CLARK COUNTY EAT RIGHT BE FIT TASK FORCE INITIATIVES, SUPPORTING THE MISSION "PROMOTING HEALTHY LIFESTYLES BY EATING RIGHT AND BEING FIT"C) MMC ACTIVELY ATTENDED AND SUPPORTED THE CLARK COUNTY HEALTH COMMUNITY PARTNER GROUP TO ASSIST IN OVERSEEING ACTION PLANS OF THE PUBLIC HEALTH INITIATIVES.D) MMC APPLIED AND WAS ACCEPTED TO BECOME AN ACCOUNTABLE CARE ORGANIZATION. THE MODEL OF DELIVERY FOCUSES ON POPULATION HEALTH MANAGEMENT FOR THE NEXT 3 YEARS.E) MMC CONTINUES TO PROVIDE AN ATHLETIC TRAINER TO NEILLSVILLE HIGH SCHOOL FOR ALL REQUESTED ACTIVITIES.F) MMC COMMUNITY EDUCATION INCLUDED- SCHOOL BASED EDUCATION, DIABETES EDUCATION, BABYSITTING CLASSES, COMMUNITY HEALTH FAIRS AND FITNESS EDUCATION.2) ACCESS TO CARE- EMPHASIS ON MENTAL/HEALTH, TRANSPORTATION AND PREVENTATIVE SCREENINGSA) MMC IMPROVED OVERALL ACCESS TO CARE BY EXPANDING OUTPATIENT CLINIC APPOINTMENTS TO 7 PM 5 DAYS A WEEK AND CONTINUED 24-HOUR URGENT CARE.B) MMC TRAINED A STAFF MEMBER TO BE A CERTIFIED NAVIGATOR FOR THE HEALTHCARE MARKET EXCHANGE. MMC ADVERTISED AND IMPLEMENTED COMMUNITY SIGN UP SESSIONS.C) MMC CONTINUES EFFORT TO RECRUIT A FULL TIME MENTAL HEALTH PROVIDERD) DUE TO PHYSICIAN COVERAGE LEAVING CLARK COUNTY, MMC PROVIDED MEDICAL COVERAGE FOR THE OAKBROOK NURSING HOME IN THORP, WI. THIS INCLUDES 24/7 COVERAGE AND MEDICAL VISITS 1-2 TIMES PER WEEK. THIS NURSING HOME IS A 55-BED FACILITY IN NORTHERN RURAL WISCONSIN.E) MMC ACTIVELY ATTENDED AND SUPPORTED THE CLARK COUNTY MENTAL HEALTH TASK FORCE INITIATIVES OF IDENTIFIED MODELS OF CARE DELIVERY FOR CLARK COUNTY RESIDENTS.F) THROUGH 2015 MMC CONTRACTED WITH CENTERPOINT COUNSELING TO PROVIDE PSYCHIATRIC CONSULTS TO SUPPORT OUR MMC PROVIDERS WITH APPROPRIATELY TREATING PRIMARY CARE PATIENTS WITH MENTAL HEALTH NEEDS THAT ARE UNABLE TO SEE A PSYCHIATRIST. G) MMC CONTINUES TO WORK WITH 3 AREA HEALTH SYSTEMS TO PROVIDE SPACE-EQUIPMENT AND STAFF FOR SPECIALISTS TO DELIVER CARE IN CLARK COUNTY.H) MMC CONTINUES TO INCREASE MEDICAL TRAINING HOURS AT FACILITY TO EXPAND APPROPRIATE CARE AND RECRUIT TO CLARK COUNTY.I) MMC COMMUNITY EDUCATION INCLUDED- STRESS MANAGEMENT, CAR SEAT TRAINING, CARDIAC REHAB TRAINING TO PREVENT ADDITIONAL CARDIAC DISEASES, MENTAL HEALTH SUPPORT GROUP, CONTINUED COMMUNITY BLOOD PRESSURE AND SPORTS SCREENINGS. THERE WERE ITEMS IDENTIFIED IN THE CHNA WHICH WERE NOT ADDRESSED BY MEMORIAL HOSPITAL, INC.; HOWEVER, ALL ITEMS WERE CONSDERED IF A NEED WAS BROUGHT TO THE ATTENTION OF THE GROUP 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 CONSTRANT OF PROVIDING A NEW SERVICE FOR A LIMITED POPULATION OF PEOPLE WITHIN THE PRIMARY SERVICE AREA OR AT THE PRESENT TIME IT WAS DETERMINED THAT A PARTNER ORGANIZATION MAY BE NEEDED TO MAKE A NEW HEALTH SERVICE A FINANCIALLY VIABLE OPTION IN THE LOCAL COMMUNITY. Memorial Hospital, Inc. Part V, Section B, Line 16i: A letter describing the hospital's financial assistance policy is sent to patients for every service provided where they are registered as a private pay patient. A letter is also sent to patients again when no payment has been received after two statements. Memorial Hospital, Inc. Part V, Section B, Line 22d: Maximum amounts that can be charged to individuals are as follows:Patients whose income is 49% or less of the Federal poverty guidelines receive free care.Patients whose income is below 200% of the Federal poverty guidelines receive the lowest negotiated commercial rate.Patients whose income is below 300% of the Federal poverty guidelines receive a 30% discount from gross charges or a 10% discount from insurance adjusted balance. 4 1 - MEMORIAL MEDICAL CENTER 216 SUNSET PLACE NEILLSVILLE WI 54456 PROVIDER-BASED RURAL HEALTH CLINIC 2 - Sunset GARDENS 216 SUNSET PLACE NEILLSVILLE WI 54456 AssisTED LIVING FACILITY 3 - LOYAL CLINIC - MEMORIAL MEDICAL CENTER 502 EAST ELM STREET LOYAL WI 54446 PROVIDER-BASED RURAL HEALTH CLINIC 4 - GREENWOOD FAMILY MEDICAL CENTER 201 SOUTH MAIN GREENWOOD WI 54437 PROVIDER-BASED RURAL HEALTH CLINIC Part I, Line 3c: Memorial Hospital, Inc. GENERALLY USES 49% OF FEDERAL POVERTY GUIDELINES FOR offering care free of charge and a sliding scale going up to 300% offering care at reduced charges. IT SHOULD also BE NOTED THAT Memorial Hospital, Inc., AS A PART OF ITS COMMUNITY CARE policy, WILL ALSO CONSIDER AN ADMINISTRATIVE REVIEW OF OTHER OUTSTANDING BALANCES OF AN INDIVIDUAL. The hospital will determine on an individual basis if additional discounts can be provided to patients. A patient may have a significant or long-term need of medical bills that may require additional community support to help a patient through a difficult time. Part I, Line 6a: Memorial Hospital, Inc. prepares a community benefit report annually and files it with the Wisconsin Hospital Association (WHA). The report is available to the general public on the WHA's website. Part I, Line 7: THE COSTING METHOD 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 DEBT, DIVIDED BY GROSS PATIENT SERVICE REVENUE. This cost-to-charge ratio is applied against various revenue and expense categories to compute the estimated community benefit expense under IRS suggested costing methods for the Form 990. Part I, Line 7g: The cost of subsidized health 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 include the operation of three family practice clinics, hospital inpatient unit, and emergency room. It is the goal of Memorial Hospital, Inc. to provide these services to the community regardless of a patient's ability to pay. Part II, Community Building Activities: COMMUNITY BUILDING ACTIVITIES PROMOTE THE HEALTH OF THE COMMUNITY that the hospital SERVEs. THROUGH COLLABORATION WITH LOCAL ORGANIZATIONS, the hospital provides information to THE COMMUNITY REGARDING VARIOUS ISSUES THAT AFFECT HEALTH SUCH AS babysitting classes, serving on public health boards, working with disaster preparedness, CPR classes, diabetic support groups, prescription assistance, stress management, preventative services, and others. Part III, Line 4: Patient Receivables and Credit Policy: In evaluating the collectability of patient accounts receivable, the Hospital analyzes past results and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for uncollectible 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 uncollectible accounts. Specifically, for receivables associated with services provided to patients who have third-party coverage, the Hospital analyzes contractually due amounts and provides an allowance for uncollectible accounts and a provision for bad debts for expected uncollectible deductible and copayments on accounts for which the third-party payor has not yet 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 Hospital records a provision for bad debts in the period of service on the basis of their 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 uncollectible accounts. The audited financial statements do not include a separate footnote regarding bad debt expense. Part III, Line 8: Memorial Hospital, Inc. is designated a critical access hospital and as such a portion of its revenues are 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 or anesthesia services at the hospital. Physician coverage is reimbursed primarily on a fee schedule reimbursement methodology at rates that are often below the cost of providing care to patients. Emergency and anesthesia services provided to Medicare patients are vital to the well-being of the community and therefore these costs and shortfalls should also be considered as an additional benefit that the hospital provides to the community and surrounding area of Neillsville, 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. 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 from services provided to Medicare beneficiaries, the recipients are typically elderly and/or disabled members of the community and are an underserved population who experience issues with access to healthcare 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 charity care policy, Memorial Hospital, Inc., makes every attempt to identify and promote charity care to patients. Included in the hospital's policy it is noted that patients may qualify for charity care either prior to admission or following discharge. UNINSURED PATIENTS ARE GIVEN THE OPPORTUNITY TO FILL OUT A Charity Care APPLICATION AT THE TIME OF ADMISSION AND ALL patientS ARE asked to fill out a charity care application DURING THE COLLECTION PROCESS prior to sending aNY ACCOUNTS TO A collection agency. If the paperwork is not received, the account is handled through the normal collection process. Part VI, Line 2: THE HOSPITAL ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITIES AND AREAS IT SERVES BY REVIEWING LOCAL DEMOGRAPHICS AND TRENDS IN PATIENT SERVICE UTILIZATION TO DETERMINE WHICH SERVICES COULD AND SHOULD BE MADE AVAILABLE TO THE COMMUNITY IN A COST-EFFECTIVE MANNER. THE HOSPITAL RECENTLY COLLABORATED WITH ANOTHER AREA HOSPITAL TO COMPLETE A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA). THE CHNA FOCUSED ON DETERMINING THE KEY HEALTH CARE PRIORITIES IN THE COMMUNITY. THE HOSPITAL ALSO SEEKS ONGOING INPUT FROM LOCAL COMMUNITY MEMBERS AND STAFF MEMBERS TO DETERMINE WHICH SERVICES MAY BENEFIT THE COMMUNITY. Part VI, Line 3: All patients who register withOUT INSURANCE are sent a private pay letter notifying them to contact a financial services representative at the hospital if they need assistance in paying their bill. The letter also highlights the charity care program and gives the website where the application can be found. The financial services representative then discusses the options available to the patient. Part VI, Line 4: THE HOSPITAL FOCUSES ON SERVING THE HEALTH NEEDS OF CLARK COUNTY WHICH HAS A POPULATION OF 35,000. THE HOSPITAL SERVES IN A COMMUNITY WHICH RANK'S IN THE THIRD LOWEST IN THE STATE OF WISCONSIN FOR PER CAPITA MONEY INCOME INCLUDING 15% OF THE POPULATION BELOW THE FEDERAL POVERTY LEVEL AND 20% OF ADULTS AND 13% OF CHILDREN ARE UNINSURED. IT IS ESTIMATED THAT APPROXIMATELY 30% OF THE COUNTY'S POPULATION IS AMISH/MENNONITE. ROUGHLY 92% OF THE POPULATION LIVES IN A RURAL AREA COMPARED TO THE STATE AVERAGE OF 30% WHICH IS SIGNIFICANT DUE TO CLARK COUNTY'S TRANSPORTATION SYSTEM BEING UNDERDEVELOPED. Part VI, Line 5: While there is growing agreement in the United States about what constitutes a non-profit hospital's community benefit, this is a work in progress. Our hospital provides charity care and other community benefits as defined by the IRS. But in addition, we believe that we provide a critically important community benefit which is not quantified. Our hospital, like most rural hospitals, was created and is maintained in order to provide care locally. Beyond inpatient hospitalizations, we provide local access to many health services: Diagnostics, Emergency Services & Urgent Care, Infusion Services, Laboratory Services, Occupational Health, Rehabilitation Services, Specialty Medicine, Sleep Center, Speech and Audiology, Surgical Services, and Womens Health Services. Part VI, Line 7, Reports Filed With States WI X X X X 0 1 0 1 0 0 0 0 0 DR DAVID CARLSON CHief Medical Officer 568606 0 222725 0 0 0 4500 0 16527 0 812358 0 0 0 DR SHARON HAYWARD PHYSICIAN 463102 0 30000 0 0 0 4500 0 26649 0 524251 0 0 0 RYAN NEVILLE PRESIDENT & CEO 228495 0 0 0 0 0 4500 0 27720 0 260715 0 0 0 DR MARIA CRUZ-APOLINARIO PHYSICIAN 253524 0 262798 0 151458 0 4500 0 24879 0 697159 0 0 0 DR Timothy Meyer PHYSICIAN 312828 0 55960 0 63403 0 4500 0 8817 0 445508 0 0 0 DR AMY SCHNEIDER DE CORTEZ PHYSICIAN 179737 0 120533 0 0 0 4500 0 20019 0 324789 0 0 0 Dr James Stanga PHYSICIAN 296573 0 465 0 0 0 4500 0 20754 0 322292 0 0 0 Dr Kenneth Weimer PhYSICIAN 249918 0 39858 0 0 0 4500 0 27315 0 321591 0 0 0 Part I, Line 4b MEMORIAL HOSPITAL, INC. OFFERS AN EXECUTIVE 457(F) RETIREMENT PLAN, ESTABLISHED IN 2006, IN WHICH THE EMPLOYER MAY MAKE DISCRETIONARY CREDITS TO THE DEFERRED COMPENSATION ACCOUNT OF THE PARTICIPANTS. THE AMOUNT CONTRIBUTED TO THE PARTICIPANTS IS DETERMINED ON AN ANNUAL BASIS BY THE EMPLOYER. Part I, Line 5 During 2015, the following physicians received compensation that was partly based on the gross charges recognized for their professional services: Dr. Timothy Meyer $55,960; Dr. Grace Cruz-Apolinario $262,798; Dr. David Carlson $222,725; Dr. Sharon Hayward $30,000; and Dr. Amy Schneider De Cortez $120,533. Chelsea Barth Daughter of Robert Barth, Board Chairman 45886 Employment compensation FOR RN SERVICES 0 Jamie Barth Daughter-in-law of Robert Barth, Board Chairman 47995 Employment Compensation FOR RESPIRATORY THERAPY 0 Thomas Silbernagel FAMILY MEMBER OF OFFICER, KELLY SILBERNAGEL 457292 OWNER OF COMPANY PROVIDING 24/7 CRNA COVEAGE 0 Linda Ormond Sister of Board Member, BarbARA Petkovsek 38379 Employment Compensation FOR PATIENT BENEFIT SPECIALIST 0 Tara Ormond NIECE OF BOARD MEMBERS, BARBARA PETKOVSEK AND ROBERT BARTH 52792 Employment Compensation FOR RN SERVICES 0 Jennifer Larson Daughter of Dr. David Carlson, Highest Compensated Employee 47444 Employment Compensation FOR PHYSICIAN ASSISTANT SERVICES 0 Kevin Grap OFFICER OF COMPANY, Kevin Grap 10220 RADIO ADVERTISING 0 Form 990, Part VI, Section B, line 11 THE CHIEF FINANCIAL OFFICER DETAIL REVIEWS THE FORM 990 PRIOR TO SUBMISSION. ALSO, BEFORE THE RETURN WAS FILED, A DRAFT COPY WAS MADE AVAILABLE TO THE BOARD OF DIRECTORS FOR REVIEW AND COMMENTS. Form 990, Part VI, Section B, line 12c Memorial Hospital, Inc. relies on the annual disclosure of key individuals to the board of directors and monitors purchases and abstentions from necessary votes throughout the year. All managers and medical staff are required to disclose and follow the conflict of interest policy. Form 990, Part VI, Section B, line 15 A COMMITTEE OF THE BOARD OF DIRECTORS HAS BEEN DESIGNATED TO REVIEW ALL EXECUTIVE PAY CHANGES. MARKET DATA IS PROVIDED TO THE COMMITTEE IN THEIR EVALUATION OF PAY CHANGES. COMPARABILITY DATA WAS USED AND THE RESULTS OF ANY EXECUTIVE PAY CHANGES WERE DOCUMENTED. NO ONE WITH A CONFLICT OF INTEREST WAS INCLUDED IN THE DECISION MAKING OF EXECUTIVE COMPENSATION. Form 990, Part VI, Section C, line 19 ALL DOCUMENTS ARE AVAILABLE UPON REQUEST. DOCUMENTS ARE ALSO DISCUSSED AT COMMUNITY MEETINGS AND EMPLOYEE FORUMS. Form 990, Part VII, Line 1A, Explanation for Hours worked: Some officers and board members also provided service to Country View, Inc., a related organization. These hours are reflected in Line 2 of Column B. Form 990, Part IX, line 11g Contracted Laboratory Services: Program service expenses 140,685. Management and general expenses 0. Fundraising expenses 0. Total expenses 140,685. contracted emergency room physicians: Program service expenses 928,800. Management and general expenses 0. Fundraising expenses 0. Total expenses 928,800. contracted anesthesia services: Program service expenses 482,392. Management and general expenses 0. Fundraising expenses 0. Total expenses 482,392. contracted radiology services: Program service expenses 604,932. Management and general expenses 0. Fundraising expenses 0. Total expenses 604,932. other contracted services: Program service expenses 544,304. Management and general expenses 0. Fundraising expenses 0. Total expenses 544,304. contracted administrative services: Program service expenses 0. Management and general expenses 800,299. Fundraising expenses 0. Total expenses 800,299. Form 990, Part XII, Line 2C: The Board of Directors is responsible for the selection of an independent auditor and management oversees the audit process. This process did not change in 2015. COUNTRY VIEW INC 216 SUNSET PLACE NEILLSVILLE WI 54456 391411586 HUD HOUSING WI 501(C)(3) Line 9 Memorial Hospital Inc 1 The Foundation of Memorial Hospital Inc 216 SUNSET PLACE NeILLSVILLE WI 54456 383800811 Fundraising WI 501(C)(3) Line 7 Memorial Hospital Inc 1 0 0 1 0 0 0 0 0 0 0 0 1 0 0 1 0 1 0 0 The Foundation of Memorial Hospital Inc C 76851 Cost