2015-05-13T10:33:21-05:00 2014-06-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2013-07-01 470533373 COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK COMM 3083442650 1301 EAST H STREET PO BOX 1328 MCCOOK NE 69001 TROY BRUNTZ CFO 3083442650 2015-05-11 1 BARBARA J FAJEN P00400874 4023302660 2013 2016-03-07 17:11:31Z TROY BRUNTZ 434 SEMINOLE DRIVE MCCOOK NE 69001 45799190 0 X WWW.CHMCCOOK.ORG X 1974 NE TO PROMOTE PUBLIC HEALTH 9 8 317 25 1118 0 3824993 793314 38782067 44246729 -96848 195074 1052539 525825 43562751 45760942 44943 49248 0 0 17225030 18925705 0 0 0 20746793 23005025 38016766 41979978 5545985 3780964 63463730 66757048 32234057 31722362 31229673 35034686 TO EXCEL AT PROVIDING FOR THE HEALTHCARE NEEDS OF OUR REGION THROUGH QUALITY, EFFICIENT AND PATIENT-CENTERED CARE. 0 0 34483910 49248 44335273 CRITICAL ACCESS ACUTE CARE HOSPITAL PROVIDING INPATIENT AND OUTPATIENT CARE, DIAGNOSTIC, REHABILITATION, SURGICAL, NURSERY, VISITING MEDICAL SPECIALISTS, HOME HEALTH AND HOSPICE, TWO RURAL HEALTH CLINICS, AND HEALTH AND EDUCATION PROGRAMS. 34483910 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 49 0 1 317 1 1 1 0 0 0 0 0 0 0 0 0 X 9 8 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X TROY BRUNTZ 3083448315 1301 EAST H - PO BOX 1328 MCCOOK NE 69001 WAYNE WATKINS DVM CHAIRMAN 1.00 0.50 X X 0 0 0 MIKE EILER VICE CHAIRMAN 1.00 0.00 X X 0 0 0 DORIS FRIEHE TREASURER 1.00 0.00 X X 0 0 0 BRUCE BAIR SECRETARY 1.00 0.00 X X 0 0 0 KRISTI DAUM MEMBER 1.00 0.50 X 0 0 0 JAMES O'DEA MEMBER THRU 12/31/13 1.00 0.50 X 0 0 0 CONNIE OLSEN MEMBER 1.00 0.50 X 0 0 0 ROSELYN REMINGTON MD MEMBER 1.00 0.00 X 0 0 0 DAVE SMITH MEMBER 1.00 0.50 X 0 0 0 TODD THIESZEN MEMBER 1.00 0.00 X 0 0 0 JAMES ULRICH CEO & PRESIDENT 39.50 0.50 X 229822 0 38453 TROY BRUNTZ CFO & VP OF FINANCE 40.00 0.00 X 161270 0 13963 BRENDA KOPRIVA GENERAL SURGEON 40.00 0.00 X 320466 0 39432 BRIAN SMITH DIRECTOR OF ANESTHESIA 40.00 0.00 X 293924 0 42063 CHAD MILLER CRNA ANESTHESIA 40.00 0.00 X 249592 0 8542 ANTHONY RODEWALD DIRECTOR OF PHARMACY 40.00 0.00 X 150332 0 32992 KAREN KLILMENT THOMPSON VP OF ANCILLARY SERVICES 40.00 0.00 X 128688 0 21470 1534094 0 196915 10 0 1 0 MCCOOK CLINIC PC 1401 EAST H STREET MCCOOK NE 69001 MEDICAL PROFESSIONAL - PHYSICIANS 1067846 SOUTHWEST NEBRASKA PHYSICAL THERAPY PC 1301 EAST H STREET MCCOOK NE 69001 PHYSICAL THERAPY SERVICES 1005141 PATHOLOGY SERVICES PC BOX 1289 NORTH PLATTE NE 69103 MEDICAL PROFESSIONAL - PATHOLOGY 296823 MB CONSTRUCTIONS MIKE BRENNING RR1 BOX 88 CULBERTSON NE 68024 CONSTRUCTION SERVICES 289975 MEDICAL SOLUTIONS 9101 WESTERN AVENUE STE 101 OMAHA NE 68114 MEDICAL SERVICES 239158 8 752955 38979 1380 793314 MEDICARE/MEDICAID PAYMENTS 621400 22016041 22016041 PATIENT SERVICE REVENUE 621400 20573341 20573341 340B PAYMENT 621400 629638 629638 RECOVERY OF ACCOUNTS 621400 539902 539902 EHR INCENTIVE PAYMENT 621400 270243 270243 217564 217564 44246729 192280 192280 261126 5631 255495 255495 255495 35411 32617 2794 2794 2794 CAFETERIA/MEALS 900099 132271 132271 HOUSEKEEPING INCOME 900099 58205 58205 PURCHASE DISCOUNTS 621400 30339 30339 49515 1118 48397 270330 45760942 44335273 1118 631237 X 49248 49248 443509 443509 34985 34985 13866130 11059299 2806831 878025 702762 175263 2581671 2022822 558849 1121385 877329 244056 28910 28910 94767 94767 5612288 4293995 1318293 181111 181111 1014136 671705 342431 957469 807537 149932 29096 13091 16005 426960 215813 211147 1361358 1213537 147821 4880488 4350547 529941 143837 128219 15618 MEDICAL SUPPLIES 5447169 5447169 PROVISION FOR BAD DEBTS 1709048 1709048 COLLECTION EXPENSE 124552 124552 MEMBERSHIPS & DUES 25413 25413 968423 736839 231584 41979978 34483910 7496068 0 1575 1675 13864502 14899810 2232751 0 5513970 6713459 159 446 1151553 1357624 732715 683046 70480618 29195576 39492382 41285042 112222 1462169 222863 231163 139038 122614 63463730 66757048 2235268 1999385 112222 176606 29395704 29420744 490863 125627 32234057 31722362 X 29038813 35034686 2190860 0 31229673 35034686 63463730 66757048 3780964 24049 0 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 1 2598 0 1 5478 8076 0 PART II-B, LINE 1: ITEM 1G - JIM ULRICH, CEO, TRAVELED TO DC AND LINCOLN TO ATTEND ADVOCACY EVENTS. ITEM 1I - A PORTION OF DUES PAID TO THE NEBRASKA CHAMBER OF COMMERCE, AMERICAN HOSPITAL ASSOCIATION AND NEBRASKA HOSPITAL ASSOCIATION ARE USED FOR LOBBYING AND POLITICAL ACTIVITIES. MANAGEMENT IS ACTIVE IN NEBRASKA HOSPITAL ASSOCIATION'S PAC, AHA'S ADVOCACY DAY, AND OTHER INDUSTRY FUNCTIONS. 2419032 5062 359249 113871 28468 2641004 2243200 5955 257537 70128 17532 2419032 2335881 6653 -30823 54809 13702 2243200 2095101 11236 408161 142894 35723 2335881 1545264 441506 165360 45171 11858 2095101 0.42030 0.57970 0.00000 0 1 1 76468 76468 25640966 15258202 10382764 43195451 13937374 29258077 1567733 1567733 41285042 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 125627 125627 X PART V, LINE 4: THE ENDOWMENT FUNDS ARE HELD BY THE COMMUNITY HOSPITAL HEALTH FOUNDATION OF MCCOOK (A RELATED PARTY) AND ARE USED IN SUPPORT OF THE HOSPITAL'S PROGRAMS AND PROJECTS, INCLUDING PROPERTY AND EQUIPMENT PURCHASES, SCHOLARSHIPS, HOSPICE PROGRAMS, REHABILITATION SERVICES AND OTHERS. PART X, LINE 2: THE HOSPITAL AND FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX-EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HOSPITAL AND FOUNDATION TO MEET A COMMUNITY BENEFIT STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. RED WILLOW IS A FOR-PROFIT CORPORATION. RED WILLOW HAD $1,003 AND $9,778 OF TAXABLE INCOME; INCURRED AND PAID $150 AND $1,467 OF FEDERAL INCOME TAX; AND INCURRED AND PAID $56 AND $546 OF STATE INCOME TAX FOR THE FISCAL YEARS ENDING DECEMBER 31, 2013 AND 2012, RESPECTIVELY. AS OF JUNE 30, 2014, RED WILLOW HAD NO TAX LIABILITY. THE HOSPITAL, FOUNDATION AND RED WILLOW ACCOUNT FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HOSPITAL, FOUNDATION AND RED WILLOW RECOGNIZE THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT JUNE 30, 2014 AND 2013, THE HOSPITAL, FOUNDATION AND RED WILLOW HAD NO UNCERTAIN TAX POSITIONS ACCRUED. THESE ENTITIES ARE NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR THE YEARS ENDED PRIOR TO JUNE 30, 2011. 1 1 1 X 150.000000000000 0 1 1 1 0 1 1 649112 649112 0.01610 2073902 2209441 -135539 0.00000 2723014 2209441 513573 0.01610 272711 179627 93084 0.00230 5205 5205 0.00010 70865 70865 0.00180 348781 179627 169154 0.00420 3071795 2389068 682727 0.02030 0 1709048 256357 18348314 19132095 -783781 X 1 1 1 1 COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK 1301 EAST H STREET - PO BOX 1328 MCCOOK NE 69001 WWW.CHMCCOOK.ORG 320007 X X X X COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK 1 1 X X X X X X X X X 13 1 0 1 X WWW.CHMCCOOK.ORG X X X 0 0 1 1 150.000000000000 0 1 X X 1 1 X X X 1 0 X X X 1 X 0 0 COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK PART V, SECTION B, LINE 3: IN CONDUCTING THE CHNA THE HOSPITAL COLLECTED DATA FROM A VARIETY OF SOURCES, INCLUDING CENSUS DATA AND HEALTH DATA FROM OTHER AGENCIES TO BEGIN THE BASIS OF OUR ASSESSMENT. WE THEN FORMULATED A STUDY DESIGNED SPECIFICALLY TO DRAW TO THE SURFACE OUR AREA'S NEEDS ACCORDING TO ITS COMMUNITY MEMBERS, HEALTHCARE PROVIDERS AND PARTNERS, WHICH INCLUDED A TELEPHONE SURVEY, FOCUS GROUPS FOR BOTH COMMUNITY MEMBERS AND THE HEALTHCARE COMMUNITY, ALONG WITH KEY INFORMANT INTERVIEWS OF COMMUNITY LEADERS. COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK PART V, SECTION B, LINE 7: THE HOSPITAL WAS NOT ABLE TO CURRENTLY ADDRESS TWO OF THE NEEDS IDENTIFIED IN THE 2013 CHNA; THE MENTAL HEALTH AND SUBSTANCE ABUSE COUNSELING NEEDS OF OUR COMMUNITY AND THE NEED FOR 24 HOUR IN-HOME CARE. WHILE THE HOSPITAL CONTINUES TO WORK IN THE INDUSTRY TO FIND ECONOMICALLY FEASIBLE SOLUTIONS TO THESE COMPLEX NEEDS, WE WERE NOT ABLE TO FURNISH OR COORDINATE ADDITIONAL COMMUNITY RESOURCES TO BETTER MEET THESE NEEDS. COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK PART V, SECTION B, LINE 11: OUR MEDICALLY INDIGENT FINANCIAL ASSISTANCE IS AVAILABLE FOR PATIENTS THAT HAVE INCURRED CATASTROPHIC MEDICAL COSTS OR OTHER OBLIGATIONS (PRESENTLY OR ONGOING) THAT HAVE SUBSTANTIALLY REDUCED THEIR ABILITY TO PAY. IN SUCH CASES, THE INDIVIDUAL OR GUARANTOR MAY BE DETERMINED BY THE HOSPITAL TO BE MEDICALLY INDIGENT AND MAY, AT THE HOSPITAL'S DISCRETION, BE ELIGIBLE FOR FINANCIAL ASSISTANCE IN THE FORM OF FREE OR DISCOUNTED LIABILITIES. COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK PART V, SECTION B, LINE 14G: THE HOSPITAL PUBLICIZED THE FINANCIAL ASSISTANCE POLICY ON BILLING INVOICES, ON POSTERS IN THE ER AND WAITING ROOMS, AT THE ADMISSIONS DESKS, INCLUDING UPON ADMISSIONS WITH SUMMARY NOTICES OF THE POLICIES. THE COMPLETE POLICY WAS AVAILABLE ON THE HOSPITAL'S WEBSITE AND UPON REQUEST. THE HOSPITAL ALSO PUBLICIZED THE POLICY THROUGH REFERRALS BY CLINICAL, SOCIAL WORKERS, AND OTHER STAFF TO THE HOSPITALS FINANCIAL COUNSELORS. COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK PART V, SECTION B, LINE 20D: THE HOSPITAL GRANTED 100% FREE CARE TO FAP ELIGIBLE INDIVIDUALS. 5 COMMUNITY HEALTHCARE & HOSPICE 407 WEST 5TH STREET MCCOOK NE 69001 HOME HEALTH AND HOSPICE SERVICES COMMUNITY HOSPITAL SLEEP LAB 801 WEST C STREET SUITE 3B MCCOOK NE 69001 OUTPATIENT SLEEP SERVICES CURTIS MEDICAL CENTER 302 EAST 6TH STREET CURTIS NE 69025 RURAL HEALTH CLINIC-OUTPATIENT SERVICES TRENTON MEDICAL CLINIC 406 EAST 1ST STREET TRENTON NE 69044 RURAL HEALTH CLINIC-OUTPATIENT SERVICES COMMUNITY HOSPITAL - OUTPATIENT SERVICES 104 NORTH 3RD STREET INDIANOLA NE 69034 OUTPATIENT SERVICES PART I, LINE 3C: CHARITY CARE IS GRANTED TO ALL INDIVIDUALS WHOSE HOUSEHOLD INCOME IS BELOW 150% OF THE FEDERAL POVERTY GUIDELINE AT THE 100% WRITE-OFF LEVEL. DISCOUNTING OR 100% WRITE-OFF TO CHARITY CARE IS ALLOWED ABOVE 150% OF THE FEDERAL POVERTY GUIDELINE BASED ON AN ANALYSIS OF INDIVIDUAL NEED AND DETERMINATION OF THE PATIENT BEING MEDICALLY INDIGENT; THIS ANALYSIS INCLUDES FACTORS SUCH AS INCOME, ACCESSIBLE ASSETS, MEDICAL OR/AND OTHER DEBTS, THE LIKELIHOOD OF ONGOING MEDICAL CARE AND THE INDIVIDUAL'S OVERALL ABILITY TO PAY. PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT IS PREPARED BY THE STAFF OF COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK. PART I, LINE 7: THE ORGANIZATION USES A COST-TO-CHARGE RATIO METHODOLOGY DERIVED FROM WORKSHEET #2 OF THE FORM 990 INSTRUCTIONS. PART I, LN 7 COL(F): THE BAD DEBT EXPENSE INCLUDED IN FORM 990, PART IX, LINE 25 BUT NOT INCLUDED IN SCHEDULE H, PART I, LINE 7, COLUMN (F) IS $1,709,048. PART II, COMMUNITY BUILDING ACTIVITIES: COMMUNITY HOSPITAL SUPPORTS VARIOUS COMMUNITY BUILDING ACTIVITIES, PRIMARILY THROUGH MONETARY SUPPORT. EXAMPLES INCLUDE SUPPORT TO THE ECONOMIC DEVELOPMENT CORPORATION, THE LOCAL COMMUNITY COLLEGE AND INVEST NEBRASKA. THESE PROGRAMS DIRECTLY IMPACT THE HEALTH OF OUR COMMUNITY BY DEVELOPMENT OF EMPLOYMENT OPPORTUNITIES AND A MORE EMPLOYABLE WORKFORCE. MEMBERS OF OUR COMMUNITY WITH GOOD EMPLOYMENT HAVE ACCESS TO HEALTH INSURANCE AND ARE GENERALLY ABLE TO LIVE HEALTHIER LIVES. PART III, LINE 2: IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL 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 DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR THOSE ACCOUNTS OVER A CERTAIN AGE BASED ON DISCHARGE 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 SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 3: LINE 3 WAS ESTIMATED USING BOTH QUANTITATIVE AND QUALITATIVE SOURCES. THE QUANTITATIVE WAS AN ANALYTICAL ANALYSIS OF THE AMOUNT OF CHARITY CARE GIVEN BY COMMUNITY HOSPITAL COMPARED TO THE LOCAL DEMOGRAPHICS FOR POVERTY BASED ON US CENSUS DATA. ONE OF THE ASSUMPTIONS MADE WAS THAT MOST INDIVIDUALS THAT WOULD HAVE QUALIFIED FOR CHARITY CARE BUT WOULD NOT APPLY ENDED UP AS BAD DEBT WRITE-OFFS OF THE HOSPITAL. THIS ANALYSIS SHOWED THAT APPROXIMATELY 15% OF THE BAD DEBT EXPENSE WAS LIKELY TO HAVE CAME FROM INDIVIDUALS THAT WOULD HAVE QUALIFIED FOR CHARITY CARE HAD THEY APPLIED. THE QUALITATIVE SOURCE WE EMPLOYED WAS TO ASK OUR STAFF THAT ROUTINELY HANDLE CHARITY CARE APPLICATIONS AND BAD DEBT DETERMINATIONS, WHAT PERCENTAGE, IN THEIR PROFESSIONAL OPINION, OF BAD DEBT WAS FROM INDIVIDUALS THAT WOULD HAVE LIKELY QUALIFIED FOR THE CHARITY CARE PROGRAM HAD THE PATIENT APPLIED FOR ASSISTANCE. THE ESTIMATE WE RECEIVED WAS 15% OF ACCOUNTS TURNED OVER AS BAD DEBT, IN THEIR OPINION, LIKELY WOULD HAVE QUALIFIED FOR CHARITY ASSISTANCE HAD THE PATIENT BEEN COOPERATIVE IN THE PROCESS AND APPLIED FOR CHARITY CARE. PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, THE FOLLOWING IS THE TEXT OF THE FOOTNOTES TITLED "PATIENT RECEIVABLES, NET," "NET PATIENT SERVICE REVENUE," AND "CHARITY CARE."PATIENT RECEIVABLES, NET:THE HOSPITAL REPORTS PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYORS, PATIENTS AND OTHERS. ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL 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 DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR THOSE ACCOUNTS OVER A CERTAIN AGE BASED ON DISCHARGE 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 SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS.NET PATIENT SERVICE REVENUE:THE HOSPITAL HAS AGREEMENTS WITH THIRD-PARTY PAYORS THAT PROVIDE FOR PAYMENTS TO THE HOSPITAL AT AMOUNTS DIFFERENT FROM ITS ESTABLISHED RATES. PAYMENT ARRANGEMENTS INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE, REIMBURSED COSTS, DISCOUNTED CHARGES AND PER DIEM PAYMENTS. NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYORS, AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYORS. RETROACTIVE ADJUSTMENTS ARE ACCRUED ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED AND ADJUSTED IN FUTURE PERIODS AS FINAL SETTLEMENTS ARE DETERMINED.CHARITY CARE:THE HOSPITAL PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE IN THE CONSOLIDATED STATEMENTS OF OPERATIONS. THE HOSPITAL IS DEDICATED TO PROVIDING COMPREHENSIVE HEALTH CARE SERVICES TO ALL SEGMENTS OF SOCIETY, INCLUDING THE AGED AND OTHERWISE ECONOMICALLY DISADVANTAGED. IN ADDITION, THE HOSPITAL PROVIDES A VARIETY OF COMMUNITY HEALTH SERVICES AT OR BELOW COST. PART III, LINE 8: THE SOURCE USED TO DETERMINE THE AMOUNT REPORTED ON LINE 6 WAS THE MEDICARE COST REPORT. NO MEDICARE SHORTFALL IS TREATED AS COMMUNITY BENEFITS. PART III, LINE 9B: COMMUNITY HOSPITAL GRANTS 100% CHARITY CARE FOR PATIENTS KNOWN TO QUALIFY FOR FINANCIAL ASSISTANCE. OUR CHARITY CARE POLICY IS SET AT 150% OF THE FEDERAL POVERTY GUIDELINE BASED FAMILY SIZE. FOR PATIENTS THAT EXCEED THE INCOME THRESHHOLD OF THE CHARITY CARE POLICY, OUR MEDICALLY INDIGENT FINANCIAL ASSISTANCE IS AVAILABLE FOR PATIENTS THAT HAVE INCURRED CATASTROPHIC MEDICAL COSTS OR OTHER OBLIGATIONS (PRESENTLY OR ONGOING) THAT HAVE SUBSTANTIALLY REDUCED THEIR ABILITY TO PAY. IN SUCH CASES, THE INDIVIDUAL OR GUARANTOR MAY BE DETERMINED BY THE HOSPITAL TO BE MEDICALLY INDIGENT AND MAY, AT THE HOSPITAL'S DISCRETION, BE ELIGIBLE FOR FINANCIAL ASSISTANCE IN THE FORM OF FREE OR DISCOUNTED LIABILITIES.CERTAIN CLASSES OF PATIENTS ARE DEEMED TO HAVE QUALIFIED FOR CHARITY CARE WITHOUT AN APPLICATION. ACCOUNTS THAT MAY QUALIFY FOR FINANCIAL ASSISTANCE WITHOUT A COMPLETED APPLICATION INCLUDE:1. MEDICAID SHARE OF COST PORTIONS.2. MEDICAID APPLICATIONS APPROVED FOR SUBSEQUENT CARE (NOT RETROACTIVE TO THE LIABILITY).3. PATIENTS OR GUARANTORS WHO HAVE DECLARED BANKRUPTCY.4. PATIENTS OR GUARANTORS WHO ARE DECEASED WITH NO ESTATE IN PROBATE AND FOR WHOM NO ONE ELSE (SUCH AS A SPOUSE OR LEGAL GUARDIAN) IS LEGALLY RESPONSIBLE FOR THE LIABILITY.5. PATIENTS OR GUARANTORS DETERMINED TO BE HOMELESS. PART VI, LINE 2: COMMUNITY HOSPITAL HAS COMPLETED A COMMUNITY HEALTH NEEDS ASSESSMENT. ACTION PLANS ARE IN PLACE TO ADDRESS SEVERAL OF THE IDENTIFIED NEEDS IN THE REPORT. PART VI, LINE 3: IDENTIFICATION OF PATIENTS WITH A POTENTIAL NEED FOR FINANCIAL ASSISTANCE WILL BE ACCOMPLISHED BY BOTH AN OPEN AND PUBLICIZED APPLICATION PROCESS AND A VARIETY OF SCREENING OPPORTUNITIES INCLUDING:A. ADMISSIONS/REGISTRATION PERSONNEL BASED UPON INFORMATION RECEIVED DURING THE REGISTRATION PROCESS.B. SOCIAL SERVICES PERSONNEL BASED UPON INFORMATION DURING THE INITIAL VISIT AND DISCHARGE PLANNING.C. NURSING STAFF BASED UPON INFORMATION RECEIVED DURING DISCUSSIONS WITH FAMILY AND/OR PATIENT.D. BUSINESS OFFICE PERSONNEL BASED UPON STATUS OF ACCOUNTS AND DISCUSSIONS WITH RESPONSIBLE PARTY.E. ACCOUNTS RECEIVABLE REPORTS.HOSPITAL STAFF OR THE NOTIFIED PATIENT ADVOCATE WILL EDUCATE THE PATIENT OR GUARANTOR ABOUT THE FINANCIAL ASSISTANCE POLICY AND WILL PROVIDE THEM AN APPLICATION FOR FINANCIAL ASSISTANCE. IF NECESSARY, THE PATIENT FINANCIAL COUNSELOR OR OTHER HOSPITAL STAFF MAY ASSIST THE PATIENT IN COMPLETING THE APPLICATION; HOWEVER, THE COMPLETION OF AN APPLICATION AND PROVIDING ALL NECESSARY SUPPORTING DOCUMENTATION IS THE PATIENT'S RESPONSIBILITY. PATIENTS MAY ALSO REQUEST AN APPLICATION OR ADDITIONAL INFORMATION IN PERSON AT THE ADMISSIONS OFFICE OR BY CALLING OR WRITING THE PATIENT FINANCIAL COUNSELOR AND AN APPLICATION WILL BE MAILED. PART VI, LINE 4: COMMUNITY HOSPITAL SERVES A PRIMARY MARKET OF RED WILLOW COUNTY, WHICH IS LOCATED ON THE SOUTHERN BORDER OF NEBRASKA. IT IS 717 SQUARE MILES AND HAS APPROXIMATELY 16.0 PEOPLE PER SQUARE MILE. MCCOOK IS THE COUNTY SEAT. COMMUNITY HOSPITAL ALSO SERVES A SECONDARY MARKET INCLUDING NORTHERN KANSAS AND SOUTHWEST NEBRASKA, WHICH CONSISTS OF FURNAS, NE, HITCHCOCK, NE, DECATUR, KS, CHEYENNE, KS, FRONTIER, NE, RAWLINS, KS AND HAYES, NE. THE TOTAL ESTIMATED POPULATION FOR COMMUNITY HOSPITAL'S SERVICE AREA IS APPROXIMATELY 31,171. RED WILLOW COUNTY HAS A POPULATION OF APPROXIMATELY 11,032. THE GROUP OF COUNTIES WHICH MAKE UP THE SECONDARY MARKET FOR COMMUNITY HOSPITAL HAVE A POPULATION OF APPROXIMATELY 20,139. THE HOUSEHOLD INCOME AVERAGES FOR THESE AREAS ARE AS FOLLOWS:15.5% $0 - 15K15.5% $15K - 25K35% $25K - 50K19% $50K - 75K7.5% $75K - 100K7% $100K+ PART VI, LINE 5: COMMUNITY HOSPITAL IS THE LARGEST HOSPITAL WITHIN AN HOUR TRAVEL TIME FOR MOST OF THE COMMUNITY SERVED. THE HOSPITAL PROVIDES THE PHYSICIANS OF MCCOOK A HOSPITAL IN WHICH TO PRACTICE MEDICINE. WITHOUT THE HOSPITAL OUR PATIENTS WOULD HAVE EXTREMELY LONG DISTANCES TO TRAVEL FOR EVERYTHING FROM EMERGENCY TO ROUTINE CARE. OUR HOSPITAL IS OVERSEEN BY A NON-COMPENSATED BOARD OF INDEPENDENT COMMUNITY MEMBERS. ANY PROFITS FROM THE OPERATION OF THE HOSPITAL ARE REINVESTED BACK INTO THE FACILITIES, EQUIPMENT AND STAFF TO PROVIDE OUR COMMUNITY WITH CURRENT AND HIGH QUALITY MEDICAL SERVICES CLOSE TO HOME. PART VI, LINE 6: N/A PART VI, LINE 7, REPORTS FILED WITH STATES NE 1 COMMUNITY HOSPITAL HEALTH FOUNDATION 801 WEST C STREET MCCOOK NE 69001 470693261 501(C)(3) 11470 TO SUPPORT THE MISSION OF THE FOUNDATION MCCOOK COLLEGE FOUNDATION PO BOX 195 MCCOOK NE 69001 476089800 501(C)(3) 20000 TO SUPPORT THE CONSTRUCTION OF THE MCC EVENT CENTER AT THE COLLEGE NEBRASKA COMMUNITY FOUNDATION PO BOX 36 MCCOOK NE 69001 470769903 501(C)(3) 5000 TO SUPPORT COMMUNITY PROJECTS 3 0 PART I, LINE 2: GRANTS ARE MADE ONLY TO SELECTED CHARITABLE OR OTHER EXEMPT ORGANIZATIONS. COMMUNITY HOSPITAL ASSOCIATION ENTERS INTO AGREEMENTS WITH GRANTEES THAT GRANT FUNDS WILL BE RESTRICTED TO SPECIFIED EXEMPT PURPOSES. X X X X 0 0 0 0 0 0 0 0 0 JAMES ULRICH CEO & PRESIDENT 229012 0 0 0 810 0 16589 0 21864 0 268275 0 0 0 TROY BRUNTZ CFO & VP OF FINANCE 160791 0 0 0 479 0 11467 0 2496 0 175233 0 0 0 BRENDA KOPRIVA GENERAL SURGEON 320014 0 0 0 452 0 17850 0 21582 0 359898 0 0 0 BRIAN SMITH DIRECTOR OF ANESTHESIA 293438 0 0 0 486 0 17850 0 24213 0 335987 0 0 0 CHAD MILLER CRNA ANESTHESIA 249020 0 0 0 572 0 8542 0 0 0 258134 0 0 0 ANTHONY RODEWALD DIRECTOR OF PHARMACY 149948 0 0 0 384 0 11021 0 21971 0 183324 0 0 0 KAREN KLILMENT THOMPSON VP OF ANCILLARY SERVICES 128308 0 0 0 380 0 9363 0 12107 0 150158 0 0 0 TROY BRUNTZ CFO MR. BRUNTZ IS THE CHIEF FINANCIAL OFFICER OF THE ORGANIZATION. EMPLOYEE COMPUTER PURCHASE X 1908 446 0 1 1 446 JESSICA JOHNSON JESSICA JOHNSON IS THE DAUGHTER OF WAYNE WATKINS, BOARD MEMBER 34985 JESSICA JOHNSON IS EMPLOYED BY THE HOSPITAL. 0 FORM 990, PART VI, SECTION A, LINE 6 THE MEMBERS CONSIST OF ALL PERSONS WHO CONTRIBUTE TO THE BUILDING AND IMPROVEMENT FUND OF THE CORPORATION, AT ANY TIME DURING THE EXISTENCE OF THE CORPORATION, NOT LESS THAN THE SUM OF $100. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERS ELECT THE BOARD OF DIRECTORS AT THE ANNUAL MEETING EACH YEAR. FORM 990, PART VI, SECTION B, LINE 11 COMMUNITY HOSPITAL'S FORM 990, 990-T AND NEBRASKA INCOME TAX FORMS ARE PREPARED BY THE PUBLIC ACCOUNTING FIRM SEIM JOHNSON. MANAGEMENT RECEIVES DRAFT COPIES OF THE COMPLETED FORMS FOR REVIEW. AFTER HOSPITAL MANAGEMENT HAS REVIEWED THE RETURNS, COMPLETE COPIES ARE DISTRIBUTED TO ALL MEMBERS OF THE BOARD OF DIRECTORS OF THE COMMUNITY HOSPITAL ASSOCIATION AND THE RETURNS ARE APPROVED FOR FILING BY THE BUDGET & FINANCE COMMITTEE OF THE BOARD (A STANDING COMMITTEE WITH RESPONSIBILITY TO OVERSEE FINANCIAL, AUDIT, TAXATION AND BUDGET MATTERS OF THE HOSPITAL). BOARD COMMITTEE APPROVAL IS REQUIRED PRIOR TO SIGNATURE AND SUBMISSION OF THE RETURNS TO THE IRS AND STATE TAXING AUTHORITIES. FORM 990, PART VI, SECTION B, LINE 12C THE COMMUNITY HOSPITAL ASSOCIATION'S CODE OF CONDUCT REQUIRES ALL EMPLOYEES, CONTRACTORS, AND AGENTS TO REPORT ANY CONFLICTS OF INTEREST THAT ARISE. IN ADDITION, THE ASSOCIATION HAS A CONFLICT OF INTEREST POLICY APPLICABLE TO DIRECTORS, OFFICERS, MEMBERS OF COMMITTEES AND SUBCOMMITTEES WITH BOARD-DELEGATED POWERS, AND KEY EMPLOYEES THAT REQUIRES, AMONG OTHER THINGS, ALL APPLICABLE PERSONS DISCLOSE ANY RELATIONSHIPS THAT MAY CREATE A CONFLICT OF INTEREST AND ARE REQUIRED TO COMPLETE AN ANNUAL DISCLOSURE OF ALL SUCH RELATIONSHIPS. ALL SUCH RELATIONSHIPS ARE DISCLOSED TO THE ENTIRE BOARD AND SENIOR MANAGEMENT, AND ANY AND ALL CONFLICTS OR POTENTIAL CONFLICTS ARE MONITORED BY SENIOR MANAGEMENT AND THE ASSOCIATION'S COMPLIANCE FUNCTION. FORM 990, PART VI, SECTION B, LINE 15 COMMUNITY HOSPITAL'S PROCESS FOR DETERMINING THE COMPENSATION OF THE CEO IS AS FOLLOWS: THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS IS RESPONSIBLE FOR SETTING THE SALARY OF THE CEO. ANNUALLY, THE COMMITTEE CONDUCTS A REVIEW OF THE CEO'S PERFORMANCE, ABILITIES, AND OVERALL EFFECTIVENESS. THE COMMITTEE IS PRESENTED WITH SALARY AND COMPENSATION SURVEY DATA THAT IS COMPILED BY THE CEO AND THE HUMAN RESOURCE DEPARTMENT AND THE ACCURACY OF WHICH IS ATTESTED TO BY THE CFO. MULTIPLE SOURCES OF SURVEY DATA ARE USED, INCLUDING INFORMATION FROM THE NEBRASKA AND IOWA HOSPITAL ASSOCIATIONS, WHICH IS BROKEN DOWN TO SIMILARLY QUALIFIED PERSONS IN COMPARABLE POSITIONS AT SIMILARLY SIZED AND SITUATED ORGANIZATIONS. ALL SOURCE DOCUMENTATION IS GIVEN TO THE COMMITTEE AS WELL AS SUMMARIES PROVIDED FOR EASE OF REFERENCE. THE EXECUTIVE COMMITTEE CONDUCTS THE PERFORMANCE REVIEW WITH THE CEO; THEN MEETS IN PRIVATE CHAMBERS TO DISCUSS THE REVIEW AND TO DELIBERATE ANY AND ALL CHANGES TO THE EMPLOYMENT AGREEMENT, INCLUDING COMPENSATION, AND GOALS FOR THE FOLLOWING YEAR. CONTEMPORANEOUS RECORDS ARE KEPT OF ALL SURVEY AND COMPARABILITY DATA USED, AND THE RESULTS AND DECISIONS OF THE EXECUTIVE COMMITTEES MEETING ON COMPENSATION. COMPENSATION OF EMPLOYEES BELOW THE ROLE OF CEO ARE DETERMINED THROUGH THE USE OF SURVEY INFORMATION OF SIMILARLY QUALIFIED PERSONS IN COMPARABLE POSITIONS AT SIMILARLY SIZED AND SITUATED ORGANIZATIONS. THE CEO SETS THE COMPENSATION OF SENIOR MANAGEMENT BASED ON THOSE SURVEYS, TAKING IN CONSIDERATION PERFORMANCE AND EXPERIENCE OF EACH INDIVIDUAL. COMPENSATION RANGES OF EMPLOYEES BELOW SENIOR MANAGEMENT ARE SET BY HUMAN RESOURCES BASED ON MARKET WAGE RATES FOR SIMILARLY QUALIFIED PERSONS IN COMPARABLE POSITIONS AT SIMILARLY SIZED AND SITUATED ORGANIZATIONS. ALL EMPLOYEES HAVE AN ANNUAL REVIEW BY THEIR SUPERVISOR, WHICH DETERMINE WHERE IN THE SALARY RANGE AN EMPLOYEE WILL FALL. ALL SALARY RANGES, INCLUDING THOSE OF SENIOR MANAGEMENT, ARE ULTIMATELY APPROVED BY THE BOARD OF DIRECTORS DURING THE APPROVAL OF THE ANNUAL OPERATING BUDGET. FORM 990, PART VI, SECTION C, LINE 19 COMMUNITY HOSPITAL MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, FORM 990 & 990-T (CURRENT AND PAST YEARS AS REQUIRED BY LAW) AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. ANY INDIVIDUAL WHO WOULD LIKE A COPY OF ANY OF THE ABOVE MENTIONED DOCUMENTS MAY INSPECT THOSE DOCUMENTS IN PERSON AT THE HOSPITAL DURING NORMAL BUSINESS HOURS, OR REQUEST A COPY OF ANY OF THE ABOVE INFORMATION IN PERSON, BY PHONE, OR BY MAIL, AND WE WILL PROVIDE A COPY FREE OF CHARGE. FORM 990, PART IX, LINE 11G MISCELLANEOUS FEES FOR SERVICE: PROGRAM SERVICE EXPENSES 1,652,430. MANAGEMENT AND GENERAL EXPENSES 680,734. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,333,164. EMERGENCY ROOM PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 1,078,006. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,078,006. LAB PATHOLOGIST FEES: PROGRAM SERVICE EXPENSES 277,071. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 277,071. PT CONTRACT SERICES: PROGRAM SERVICE EXPENSES 981,317. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 981,317. IS MAINTENANCE AGREEMENT: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 637,559. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 637,559. NUCLEAR MED MOBILE SERVICES: PROGRAM SERVICE EXPENSES 305,171. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 305,171. FORM 990, PART XII, LINE 2C COMMUNITY HOSPITAL HAS A STANDING BOARD COMMITTEE, THE BUDGET AND FINANCE COMMITTEE, WHICH HAS THE AUTHORITY AND ASSUMES THE RESPONSIBILITY FOR THE SELECTION OF THE INDEPENDENT ACCOUNTING FIRM AND ALL RELATED OVERSIGHT, COMMUNICATION, AND REPORTING. THIS COMMITTEE APPROVES ALL ENGAGEMENT LETTERS AND RECEIVES ALL BOARD DIRECTED COMMUNICATION FROM THE INDEPENDENT ACCOUNTING FIRM. COPIES OF RECEIVED LETTERS/COMMUNICATIONS AND REPORTS ARE DISTRIBUTED TO ALL MEMBERS OF THE BOARD OF DIRECTORS IN ADDITION TO THE COMMITTEE MEMBERS. WHILE THE MEMBERS OF THE COMMITTEE HAVE CHANGED, THE PROCESS DESCRIBED HAS NOT CHANGED FROM THE PREVIOUS YEAR. COMMUNITY HOSPITAL HEALTH FOUNDATION 801 WEST C STREET PO BOX 1328 MCCOOK NE 69001 470693261 SUPPORTING ORGANIZATION PROVIDES FUNDRAISING FOR THE HOSPITAL NE 501(C)(3) LINE 11A, I COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK 1 RED WILLOW HOLDING COMPANY PO BOX 1328 MCCOOK NE 69001 470628195 RENTAL REAL ESTATE - CLINIC BUILDING NE COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK C 50353 146329 1.00000 1 0 0 1 0 0 0 0 0 0 0 1 0 1 1 1 1 1 0 0 COMMUNITY HOSPITAL HEALTH FOUNDATION C 752955 CASH RECEIVED=FMV