2015-05-07T05:20:39-05:00 2014-06-30 550486667 Arnett Carbis Toothman LLP P O Box 2629 Charleston WV 25329 990 2013-07-01 550477361 Boone Memorial Hospital Inc BOON 3043691230 701 Madison Avenue Madison WV 25130 Randell Foxx Interim CEO 3043691230 2015-04-29 1 Harry C Harless P01042847 3043460441 2013 2016-02-25 16:41:14Z Randell Foxx 701 Madison Avenue Madison WV 25130 29116435 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. 9 9 227 36 0 0 108186 139949 25303619 28657487 300371 14481 352661 250993 26064837 29062910 119300 22220 0 0 9677958 10566069 0 150000 150000 16399980 18088332 26197238 28826621 -132401 236289 10933595 11100076 4154256 4084448 6779339 7015628 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. 1 0 24364684 22220 28490348 In performing its mission, Boone Memorial Hospital had 405 acute care admissions and 158 skilled nursing care admissions. The Hospital also had 47 respite care patients, 12,219 emergency room visits, 20,072 out-patient visits and 22,370 visits in its two rural health clinics. 6338 16919 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. There were 448 community members who attended the health fair and approximately 220 received low cost blood work. 304636 150220 BMH Respite Care Program. The Hospital had 47 respite care admissions and 1,295 respite days for its 6/30/14 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. 24675658 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 48 0 1 227 1 0 0 0 0 0 0 0 0 0 0 X 9 9 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 0 0 0 James Hensley Vice President 1.30 X 0 0 0 Janet Yeager Secretary 1.30 X 0 0 0 Thomas Bias 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 Virgil Underwood 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 Tommy H Mullins CEO 40.00 X 140505 0 97014 Randell D Foxx CFO/Interim CEO 40.00 X 126193 0 18728 Ziad Chanaa Physician 40.00 X 156758 0 78908 Kevin Hill PA 40.00 X 153901 0 16241 Tara Cogar PA 40.00 X 120069 0 13576 Blitz Turner NP 40.00 X 110186 0 15159 Christina Stover PA 40.00 X 110047 0 7654 917659 0 247280 8 0 1 0 Rehab One Ltd 1834 Park Avenue Belle WV 25015 Physical Therapy Services 938921 CPSI PO Box 850309 Mobile AL 36685 System Software Vendor 898330 Kreps and Zachwieja 300 Capitol Street Suite 1710 Charleston WV 25301 Architectual Services 685837 Pharmacy Management & Consulting Service 928 Helene Street St Albans WV 25177 Pharmacy services 641682 CAMC Labworks PO Box 388 Charleston WV 25323 Reference Lab 559878 28 37276 102673 139949 Patient Service Revenue 624100 27915601 27915601 340B Program Revenue 624100 741886 741886 28657487 68006 68006 275 0 275 275 275 53525 -53525 -53525 -53525 Pharmacy 446110 94492 94492 Health fair 900099 92029 92029 Dietary Sales 722210 45784 45784 18413 18413 250718 29062910 28657487 0 265474 X 22220 22220 392707 295787 96920 7851847 5914011 1937836 84044 63302 20742 1629914 1227651 402263 607557 457612 149945 113954 113954 150000 150000 7068198 6720166 348032 78648 78648 1884032 1419053 464979 200693 151162 49531 217004 163447 53557 11284 8499 2785 41061 30927 10134 24965 18804 6161 532639 401184 131455 353906 266562 87344 Bad debt expense 5726471 5726471 Medical supplies 1143222 1143222 Provider tax 500076 500076 192179 145502 46677 28826621 24675658 4000963 150000 1973903 938174 2159761 1151525 2207520 2934345 111037 194160 256944 279964 31837 31386 11561069 7259035 3022768 4302034 258940 161806 910885 1053140 0 53542 10933595 11100076 2498618 2860704 392 392 419897 231067 1235349 992285 4154256 4084448 X 6779339 7015628 6779339 7015628 10933595 11100076 236289 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 216178 216178 1304828 1051148 253680 7030847 6119288 911559 3009216 88599 2920617 4302034 Other investment securities 1053140 C 1053140 Deferred compensation 992285 992285 23336439 0 23336439 5726471 5726471 29062910 23100150 0 23100150 5726471 5726471 28826621 Part XI, Line 4b - Other Adjustments: Bad debt expense netted with revenue on financial statements 5,726,471. Part XII, Line 4b - Other Adjustments: Bad debt expense netted with revenue on financial statements 5,726,471. X X X 1 D A Consulting LLC 6 Canyon Road Suite 300 Morgantown WV 26508 Raise funds for construction of new hopsital. 0 50319 150000 50319 50319 150000 50319 WV 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 1 0 0 582524 1467000 -884476 0.00000 5046860 5158841 -111981 0.00000 5629384 6625841 -996457 5629384 6625841 -996457 14 2990 2990 0.00010 14 2990 2990 0.00010 1 5726471 4588709 4657879 -69170 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, swing bed Boone Memorial Hospital Inc 1 1 X X X 12 1 0 1 X http://bmh.org/ X X 1 0 1 1 200.000000000000 1 200.000000000000 1 X X X X X 1 1 X X X X 1 0 X X X 1 X 0 0 Boone Memorial Hospital, Inc. Part V, Section B, Line 3: 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 10: 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 patients Total Yearly Income, verification of the patients Total Yearly Income can be done in either of the following ways:1. Obtaining the patient's or responsible partys Written Attestation. By obtaining an Application signed by the patient or responsible party attesting to the veracity of the patients Total Yearly Income information provided: or2. Obtaining the patient's or responsible partys Verbal Attestation. Through the written attestation of the BMH employee completing the Assistance Application that the patient or responsible party verbally verified the patients Total Yearly Income information provided.3. In instances where the patient or responsible party is unable to provide the requested third party verification of patients 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. Boone Memorial Hospital, Inc. Part V, Section B, Line 14g: The Financial Assistance Eligibility Discount Guidelines will be updated annually in accordance with the FPG as published in the Federal Register by the U.S. Department of Health and Human Services.The Application is effective for all outstanding patient accounts and for all accounts discharged six months after the Application is signed by the patient, immediate family member or patient representative. The Application may be extended for an additional six months by any of the same with affirmation of the Number in Household and the patient's reported Total Yearly Income.4. 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. 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/ore. Financial Counselors visiting with BMH inpatients.5. NON-PAYMENTAfter 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 patient accounts. Patients will be invoiced for any remaining amounts in accordance with other BMH Debt Collection Policies regarding this matter.6. REASONS FOR DENIALa. BMH reserves the right to exclude certain services from being covered under this Financial Assistance Policy;b. Financial assistance will be denied to a patient if the patient, an immediate family member, or the patients representative provides false information on the Application including information regarding the Total Yearly Income, the Number in Household, assets or other resources available that might indicate a financial means to pay for care; orc. An Application will be denied if the patient receives a third party financial settlement associated with the care rendered, in which case the patient is expected to use the settlement amount to satisfy any outstanding accounts. Boone Memorial Hospital, Inc. Part V, Section B, Line 20d: 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 $ 5,726,471. Part II, Community Building Activities: Community support mainly consists of sponsorships for little league and high school athletics and volunteer organizations. 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 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 1 10000 Cash - FMV Student loan assistance to professional employees X 0 1 0 0 0 0 0 0 0 Tommy H Mullins CEO 140505 0 0 0 0 0 87416 0 11610 0 239531 0 0 0 Ziad Chanaa Physician 156758 0 0 0 0 0 66000 0 12908 0 235666 0 0 0 Kevin Hill PA 153901 0 0 0 0 0 3333 0 13998 0 171232 0 0 0 Part I, Line 4b Tommy H. Mullins, CEO, participated in a 457(f) plan during 2014. Form 990, Part III, line 2 The Hospital opened a Suboxone Clinic in October 2013. Form 990, Part VI, Section B, line 11 Randell Foxx, Interim CEO 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 on request. Form 990, Part IX, line 11g Surgery: Program service expenses 290,878. Management and general expenses 0. Fundraising expenses 0. Total expenses 290,878. Radiology: Program service expenses 484,537. Management and general expenses 0. Fundraising expenses 0. Total expenses 484,537. Pharmacy: Program service expenses 638,922. Management and general expenses 0. Fundraising expenses 0. Total expenses 638,922. Physicians: Program service expenses 2,443,962. Management and general expenses 0. Fundraising expenses 0. Total expenses 2,443,962. Lab: Program service expenses 567,050. Management and general expenses 0. Fundraising expenses 0. Total expenses 567,050. Emergency room: Program service expenses 155,529. Management and general expenses 0. Fundraising expenses 0. Total expenses 155,529. Physical therapy: Program service expenses 1,077,142. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,077,142. Administrative: Program service expenses 771,822. Management and general expenses 252,902. Fundraising expenses 0. Total expenses 1,024,724. All other: Program service expenses 290,324. Management and general expenses 95,130. Fundraising expenses 0. Total expenses 385,454.