2016-05-13T13:15:25-05:00 2015-06-30 550486667 Arnett Carbis Toothman LLP P O Box 2629 Charleston WV 25329 990 2014-07-01 550477361 Boone Memorial Hospital Inc BOON 3043691230 701 Madison Avenue Madison WV 25130 Randell Foxx CFO 3043691230 2016-05-10 1 Tessa W Carr P01291277 3043460441 2014 2016-08-17 19:52:53Z Virgil Underwood 701 Madison Avenue Madison WV 25130 28551213 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 8 223 35 0 0 139949 480271 28657487 27143518 14481 102551 250993 713167 29062910 28439507 22220 45097 0 0 10566069 10544537 150000 50051 84733 18088332 16250120 28826621 26889805 236289 1549702 11100076 26881258 4084448 18315928 7015628 8565330 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 22255177 27789295 In performing its mission, Boone Memorial Hospital had 476 acute care admissions and 117 skilled nursing care admissions. The Hospital also had 15 respite care patients, 12,116 emergency room visits, 19,543 out-patient visits and 22,855 visits in its two rural health clinics. 6249 15974 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 500 community members attended the health fair and approximately 250 received low cost blood work. 135461 61043 BMH Respite Care Program. The Hospital had 15 respite care admissions and 642 respite days for its 6/30/15 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. 45097 45097 Boone Memorial Hospital provides student loans to medical professionals and and then grants loan forgiveness periodically during their employment. During the fiscal year ended June 30, 2015 10 individuals were granted forgiveness for a portion of their student loan. 45097 45097 22441984 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 0 1 0 0 0 0 0 0 1 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 45 0 223 1 0 0 0 0 0 0 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 Janet Yeager Board Member 1.30 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 HH Howell Board Member 1.30 X 0 0 0 Nada Woodie Board Member 1.30 X 0 0 0 Virgil Underwood Board Member/CEO as of 2/9/15 1.30 X X 0 0 0 Tommy H Mullins CEO 7/2014 to 12/2014 40.00 X 199713 0 118308 Randell D Foxx CFO/Interim Co-CEO 12/2014-2/2015 40.00 X 138134 0 15881 Mark Linville Interim Co-CEO 12/2014-2/2015 40.00 X 92238 0 14553 Ziad Channa Physician 40.00 X 170633 0 78739 Kevin Hill PA 40.00 X 173662 0 16159 Tara Hager PA 40.00 X 132024 0 11360 Blitz Turner NP 40.00 X 113755 0 13170 Kristina Stover PA 40.00 X 119314 0 6615 1139473 0 274785 9 0 1 0 Neighborgall Construction Co 1216 Seventh Avenue Huntington WV 25701 General Contractor-New Hospital 5947935 Cherry River Construction LLC 85 Legacy Ridge Red House WV 25168 General Contractor-New Hospital 1407872 CPSI PO Box 850309 Mobile AL 36685 System Software Vendor 1025840 Rehab One Ltd 1834 Park Avenue Belle WV 25015 Physical Therapy Services 862271 41 41318 9360 429593 480271 Patient Service Revenue 622110 26137498 26137498 340B Program Revenue 900099 1006020 1006020 27143518 180100 180100 150 0 150 150 150 22500 100049 -77549 -77549 -77549 1880 41318 11657 -9777 -9777 EHR Incentive Revenue 900099 434891 434891 Pharmacy 446110 119111 119111 Dietary Sales 900099 53780 53780 115012 115012 722794 28439507 27866312 0 92924 X 45097 45097 558428 411952 146476 7768562 5730868 2037694 89147 65764 23383 1477749 1090135 387614 650651 479985 170666 131200 131200 72167 72167 50051 50051 7793632 7349729 443903 90589 90589 1832347 1351722 480625 41416 30553 10863 196767 145155 51612 11579 8542 3037 35665 26310 9355 10979 8099 2880 486854 359152 127702 512629 378166 134463 Bad debt expense 2599465 2599465 Medical supplies 1522203 1522203 Provider tax 537102 537102 Charity Care Expense 137427 137427 238099 164558 38859 34682 26889805 22441984 4363088 84733 938174 5798867 1151525 1264943 9360 2934345 2830681 194160 61929 279964 310245 31386 144502 21517175 6428812 4302034 15088363 161806 191255 1053140 1181113 53542 0 11100076 26881258 2860704 5569688 392 383595 231067 8835974 992285 3526671 4084448 18315928 X 7015628 8160858 404472 7015628 8565330 11100076 26881258 1549702 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 404472 404472 1.00000 0 0 216178 216178 1197671 1034061 163610 5815604 5307615 507989 14287722 87136 14200586 15088363 Deferred compensation 1025921 Third Party Payor Settlements 2500750 3526671 25714272 11657 11657 25702615 2736892 2736892 28439507 24164570 11657 11657 24152913 2736892 2736892 26889805 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 11,657. Part XI, Line 4b - Other Adjustments: Bad debt expense netted with revenue on financial statements 2,599,465. Charity care expense netted with revenue on financial statements 137,427. Part XII, Line 2d - Other Adjustments: Direct fundraising expense netted against fundraising income 11,657. Part XII, Line 4b - Other Adjustments: Bad debt expense netted with revenue on financial statements 2,599,465. Charity care expense netted with revenue on financial statements 137,427. X X X 1 D A Consulting LLC 6 Canyon Road Suite 300 Morgantown WV 26508 Raise funds for construction of new hospital. 0 404472 50051 354421 404472 50051 354421 WV Golf Tournament 43198 41318 1880 3000 6657 125 1875 43198 41318 1880 3000 6657 125 1875 11657 -9777 Schedule G, Part I, Line 2b, Column (v) The Hospital contracted with a professional fundraiser, D. A. Consulting, LLC, to organize and implement a feasibility study and develop a comprehensive capital campaign plan and strategy to raise $5,000,000 for construction of a new hospital. 1 1 X 1 X 1 X 0 1 0 0 589458 589458 6844708 6844708 7434166 7434166 141810 77017 64793 0.00270 5784 5784 0.00020 147594 77017 70577 0.00290 7581760 7511183 70577 0.00290 0 990321 4536436 4536436 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 12 1 0 0 1 X http://bmh.org/ X 1 12 0 0 0 1 X 200.000000000000 200.000000000000 X X X X 1 1 X X 1 X X X X X 1 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. 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 the same rates as every other patient with insurance. A prompt pay discount of 15% is offered if the account is paid in full within 30 days of the first statement. 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 patients 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 $ 2,599,465. 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 6/30/15. 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 leaders, health care providers, and 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.-Collected secondary data sources such as information from the Boone County Health Department Community Needs Assessment, State health statistics and behavioral risk assessments, US Census Data, Centers for Disease Control statistics and data, etc.-Created a comprehensive database including answers to each survey question which was used to track and calculate the data.-Held focus groups, some of which included youth representation in order to obtain a diverse range of responses in an open discussion format. 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 24,224 in 2013. The median household income was $41,359 with 18.9% below the federal poverty guideline. 15% of the population is over 65 and 28.9% is under 18 with 40.7 years as the median age. 79% of the hospital's patients were from Boone County is FY 13.Logan County had an estimated population of 35,987 in 2013. The median household income was $36,698 with 20.8% below the federal poverty guideline. 16% of the population is over 65 and 26% is under 18. 12% of the hospital's patients were from Logan County in FY 13. Lincoln County had an estimated population of 21,559 in 2013. The median household income was $34,066 with 26.9% below the federal poverty guideline. 16% of the population is over 65 and 28% is under 18. 7% of the hospital's patients were Lincoln County in FY 13. 23% of the hospital's patients were age 65+ for FY 2013. 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 10 45097 Cash - FMV Student loan assistance to professional employees X 0 1 0 0 0 0 0 0 0 Tommy H Mullins CEO 7/2014 to 12/2014 199713 0 0 0 0 0 110841 0 10368 0 320922 0 0 0 Randell D Foxx CFO/Interim Co-CEO 12/2014-2/2015 138134 0 0 0 0 0 3141 0 15845 0 157120 0 0 0 Ziad Channa Physician 170633 0 0 0 0 0 66000 0 12907 0 249540 0 0 0 Kevin Hill PA 173662 0 0 0 0 0 3420 0 13998 0 191080 0 0 0 Part I, Line 4b Tommy H. Mullins, CEO, participated in a 457(f) plan during 2014 and $107,973 was contributed to the plan during the year. 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 446,214. Management and general expenses 0. Fundraising expenses 0. Total expenses 446,214. Radiology: Program service expenses 475,635. Management and general expenses 0. Fundraising expenses 0. Total expenses 475,635. Pharmacy: Program service expenses 656,242. Management and general expenses 0. Fundraising expenses 0. Total expenses 656,242. Physicians: Program service expenses 2,713,952. Management and general expenses 0. Fundraising expenses 0. Total expenses 2,713,952. Lab: Program service expenses 644,713. Management and general expenses 0. Fundraising expenses 0. Total expenses 644,713. Emergency room: Program service expenses 66,084. Management and general expenses 0. Fundraising expenses 0. Total expenses 66,084. Physical therapy: Program service expenses 1,098,442. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,098,442. Administrative: Program service expenses 774,858. Management and general expenses 275,512. Fundraising expenses 0. Total expenses 1,050,370. All other: Program service expenses 473,589. Management and general expenses 168,391. Fundraising expenses 0. Total expenses 641,980.