2014-09-23T15:47:13-05:00 2013-12-31 340641962 BRUNER-COX LLP 388 S MAIN STREET SUITE 403 AKRON OH 44311 990 2013-01-01 340726081 ASHTABULA COUNTY MEDICAL CENTER ASHT 4409972262 2420 LAKE AVENUE ASHTABULA OH 44004 DON KEPNER VP FINANCE/CFO 4409972262 2014-09-17 1 LISA M HILLING P01624111 3303760100 2013 2015-11-30 17:44:51Z MICHAEL HABOWSKI 2420 LAKE AVENUE ASHTABULA OH 44004 131123819 0 6026 X WWWW.ACMCHEALTH.ORG X 1902 OH TO PROVIDE THE BEST POSSIBLE MEDICAL CARE THROUGH ALL PHASES OF LIFE TO THOSE SEEKING HELP. THE ASHTABULA COUNTY MEDICAL CENTER HEALTH CARE TEAM IS COMMITTED TO PRESERVING THE HUMAN RIGHTS AND DIGNITY OF THOSE WHO RECEIVE OUR CARE AND THOSE WHO PROVIDE IT. 18 10 1133 175 427804 -15703 132524 309477 92064157 97068000 73982 1505390 3140126 3900374 95410789 102783241 0 0 0 0 52070157 57157272 0 0 0 41609505 42934865 93679662 100092137 1731127 2691104 95767852 107823161 63550074 57113142 32217778 50710019 TO PROVIDE THE BEST POSSIBLE MEDICAL CARE THROUGH ALL PHASES OF LIFE TO THOSE SEEKING HELP. THE ASHTABULA COUNTY MEDICAL CENTER HEALTH CARE TEAM IS COMMITTED TO PRESERVING THE HUMAN RIGHTS AND DIGNITY OF THOSE WHO RECEIVE OUR CARE AND THOSE WHO PROVIDE IT. 0 0 82075551 100493904 ASHTABULA COUNTY MEDICAL CENTER (ACMC) IS A PRIVATE, NOT-FOR-PROFIT, COMMUNITY-ORIENTED MEDICAL CENTER THAT PROVIDES THE BEST POSSIBLE MEDICAL CARE THROUGH ALL PHASES OF LIFE TO THOSE SEEKING HELP. IN 2013 WE MET OUR MISSION OF MEETING OUR COMMUNITY'S HEALTH CARE NEEDS AS EVIDENCED BY APPROXIMATELY 33,087 EMERGENCY DEPARTMENT VISITS, 5,859 INPATIENT DISCHARGES, 1,268 INPATIENT SURGERIES, 6,320 OUTPATIENT SURGERIES, 425 BIRTHS, AND 66,056 RADIOLOGY PROCEDURES. 82075551 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 1 1 1 0 0 0 0 0 1 0 0 0 1 88 0 1133 1 1 1 0 0 0 0 0 0 0 0 0 X 18 10 1 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X DON KEPNER VP FINANCECFO 4409972262 2420 LAKE AVENUE ASHTABULA OH 44004 X JOE GIANGOLA CHAIRMAN 0.30 0.30 X X 0 0 0 SUSAN STOCKER PHD VICE CHAIRMAN 0.30 0.30 X X 0 0 0 BILL DINGLEDINE SECRETARY/TREASURER 0.30 0.30 X X 0 0 0 MICHAEL HABOWSKI PRESIDENT/CEO 40.00 0.30 X X 0 0 0 NEROY CARTER BOARD MEMBER 0.30 0.30 X 0 0 0 JEFF COXEN BOARD MEMBER 0.30 0.30 X 0 0 0 ELEANOR JAMMAL BOARD MEMBER 0.30 0.30 X 0 0 0 PEG CARLO BOARD MEMBER 0.30 0.30 X 0 0 0 NANCY KISTER BOARD MEMBER 0.30 0.30 X 0 0 0 JOE VENDEL BOARD MEMBER 0.30 0.30 X 0 0 0 STEVE DAVIS MD BOARD MEMBER/CCF REPRESENTATIVE 0.30 0.30 X 0 0 0 JUDE CAUWENBERGH DO BOARD MEMBER/PHYSICIAN REP 60.00 0.30 X 290333 0 10138 FRED DEGRANDIS BOARD MEMBER/CCF REPRESENTATIVE 0.30 0.30 X 0 0 0 JASON HERGENROEDER BOARD MEMBER/CCF REPRESENTATIVE 0.30 0.30 X 0 0 0 SUK K CHOI MD BOARD MEMBER/PHYSICIAN REP 60.00 0.30 X 704634 0 16365 ROBERT DLWGOSH MD BOARD MEMBER/PHYSICIAN REP 60.00 0.30 X 408974 0 13274 ASHOK V KONDRU MD BOARD MEMBER/PHYSICIAN REP 40.00 0.30 X 30770 0 0 NAFISA KONDRU MD BOARD MEMBER/PHYSICIAN REP 1.00 0.30 X 5100 0 0 STEVE WALLING BOARD MEMBER 0.30 0.30 X 0 0 0 DON KEPNER VP FINANCE/CFO 40.00 0.30 X 0 0 0 ALEXANDER TAICH MD PHYSICIAN 60.00 0.00 X 812962 0 10702 JAMES CHILLCOTT MD PHYSICIAN 60.00 0.00 X 630478 0 17091 LAXMAN R CINGIREDDI MD PHYSICIAN 60.00 0.00 X 573745 0 12991 YISA B SUNMONU MD PHYSICIAN 60.00 0.00 X 530334 0 16572 MICHAEL J PAPSIDERO MD PHYSICIAN 60.00 0.00 X 490157 0 16349 4477487 0 113482 45 0 1 0 CLEVELAND CLINIC FOUNDATION PO BOX 931760 CLEVELAND OH 44193 ADMINISTRATIVE SERVICES 6157015 ARAMARK CORP 24863 NETWORK PLACE CHICAGO IL 60673 CAFETERIA AND DIETARY SERVICES 1936578 HMP OF ASHTABULA COUNTY LTD PO BOX 645037 CINCINNATI OH 45264 HOSPITALISTS 976058 SS&G HEALTHCARE SERVICES PO BOX 39453 CLEVELAND OH 44139 PHYSICIAN BILLING SERVICE 801646 CLEVELAND CLINIC FOUNDATION DBA CLEVELAN PO BOX 931720 CLEVELAND OH 44193 LABORATORY TESTING 662072 19 309477 309477 NET PATIENT SERVICE RE 624100 97068000 97068000 97068000 665533 665533 46666 0 46666 46666 46666 29180435 28340578 839857 839857 839857 MISC OPERATING REVENUE 624100 3240544 3240544 PREMIER FITNESS AND DA 713940 427804 427804 REBATES AND REFUNDS 624100 185360 185360 3853708 102783241 100493904 427804 1552056 1749084 1434249 314835 43111404 35351351 7760053 3238937 2655928 583009 6061309 4970273 1091036 2996538 2457161 539377 163887 134387 29500 59000 48380 10620 1522728 1248637 274091 71932 58984 12948 19693 16148 3545 3681639 3018944 662695 782449 641608 140841 SUPPLIES 16160967 13251993 2908974 MEDICAL SERVICES & FEES 7619435 6247937 1371498 EQUIPMENT RENTAL/MAINTE 4375224 3587684 787540 PURCHASED ADMINISTRATIV 3296649 2703252 593397 5181262 4248635 932627 100092137 82075551 18016586 0 39190673 13409770 921254 349031 12640298 14409715 150000 904986 872121 1228008 1291309 93890589 71682226 20098768 22208363 10848868 44101524 2430378 2616043 7504619 8415285 95767852 107823161 15262269 16053632 305649 48287805 40753861 63550074 57113142 X 32202803 50653544 14975 56475 32217778 50710019 95767852 107823161 X 2691104 299411 15501726 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1900567 1900567 26918987 20211345 6707642 2151231 1774296 376935 62441684 49696585 12745099 478120 478120 22208363 SELF-INSURANCE INVESTMENTS 5667409 DEFERRED COMPENSATION 2689654 OTHER ASSETS 33774 DUE FROM AFFLIATES 24448 8415285 RESERVE FOR SELF-INSURANCE LIABILITIES 11128012 DEFERRED COMPENSATION 2689654 ACCRUED PENSION LIABILITY 7135999 DISTRIBUTION PAYABLE TO THE CLEVELAND CLINIC FOUNDATION 2364250 INVESTMENT FROM CLEVELAND CLINIC FOUNDATION 15000000 THIRD-PARTY PAYABLES 2062273 CAPITAL LEASES 373673 40753861 X PART X, LINE 2: WHEN TAX RETURNS ARE FILED, IT IS HIGHLY CERTAIN THAT SOME POSITIONS TAKEN WOULD BE SUSTAINED UPON EXAMINATION BY THE TAXING AUTHORITIES, WHILE OTHERS ARE SUBJECT TO UNCERTAINTY ABOUT THE MERITS OF THE POSITION TAKEN OR THE AMOUNT OF THE POSITION THAT WOULD BE ULTIMATELY SUSTAINED. IN ACCORDANCE WITH THE INCOME TAXES TOPIC OF THE FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ACCOUNTING STANDARDS CODIFICATION, THE BENEFIT OF A TAX POSITION IS RECOGNIZED IN THE FINANCIAL STATEMENTS IN THE PERIOD DURING WHICH, BASED ON ALL AVAILABLE EVIDENCE, MANAGEMENT BELIEVES IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINED UPON EXAMINATION, INCLUDING THE RESOLUTION OF APPEALS OR LITIGATION PROCESSES, IF ANY. TAX POSITIONS TAKEN ARE NOT OFFSET OR AGGREGATED WITH OTHER POSITIONS. TAX POSITIONS THAT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD ARE MEASURED AS THE LARGEST AMOUNT OF TAX BENEFIT THAT IS MORE THAN 50% LIKELY OF BEING REALIZED UPON SETTLEMENT WITH THE APPLICABLE TAXING AUTHORITY. THE PORTION OF THE BENEFITS ASSOCIATED WITH TAX POSITIONS TAKEN THAT EXCEEDS THE AMOUNT MEASURED AS DESCRIBED ABOVE IS RECORDED AS A LIABILITY FOR UNRECOGNIZED TAX BENEFITS ALONG WITH ANY ASSOCIATED INTEREST AND PENALTIES THAT WOULD BE PAYABLE TO THE TAXING AUTHORITIES UPON EXAMINATION. 1 1 X 1 X 0 1 1 0 743531 743531 0.00740 15097776 14215663 882113 0.00880 682435 300413 382022 0.00380 16523742 14516076 2007666 0.02000 2418717 2418717 0.02420 36699 36699 0.00040 38823 38823 0.00040 10348 10348 0.00010 2504587 2504587 0.02510 19028329 14516076 4512253 0.04510 1 9849975 0 28418523 28467731 -49208 X 1 1 1 1 ASHTABULA COUNTY MEDICAL CENTER 2420 LAKE AVENUE ASTHABULA OH 44004 X X X ASHTABULA COUNTY MEDICAL CENTER 1 1 X X X X X X X X 13 1 0 1 X X X X X X 0 0 1 1 200.000000000000 0 1 X 1 1 X X X 1 0 X X X X 1 X 0 1 ASHTABULA COUNTY MEDICAL CENTER PART V, SECTION B, LINE 3: KEY INFORMANT SURVEYS WERE CONDUCTED WITH 12 PROFESSIONALS AND KEY CONTACTS FROM THROUGHOUT ASHTABULA COUNTY. WORKING WITH THE LEADERSHIP FROM ACMC, 21 PROSPECTIVE INDIVIDUALS WERE IDENTIFIED AND INVITED TO PARTICIPATE IN THE STUDY. THE KEY INFORMANTS INCLUDED ELECTED OFFICIALS, HEALTHCARE PROVIDERS, HEALTH AND HUMAN SERVICES EXPERTS, AND LEADERSHIP FROM VARIOUS AREA NON-PROFIT ORGANIZATIONS. THE CONTENT OF THE QUESTIONNAIRE FOCUSED ON KEY HEALTH CONCERNS, ACCESS TO CARE, AND EXISTING COMMUNITY ASSETS AND RESOURCES. QUESTIONS INCLUDED BOTH OPEN-ENDED ITEMS TO GATHER QUALITATIVE FEEDBACK, AS WELL AS, QUESTIONS TO WHICH RESPONDENTS PROVIDED RATINGS. IT SHOULD BE NOTED THAT WHILE THE KEY INFORMANT FEEDBACK IS INFORMATIVE AND HELPFUL WITH UNDERSTANDING COMMUNITY NEEDS, THE SMALL NUMBER OF COMPLETED INTERVIEWS DOES NOT ALLOW FOR STATISTICAL GENERALIZATION TO THE POPULATION AS A WHOLE. THE KEY INFORMANT PARTICIPANTS WERE TANIA BURNETTE, CHILDREN'S SERVICES BOARD; DAN CLAYPOOL, ASHTABULA COUNTY COMMISSIONER; MIKE HABOWSKI, ACMC; IMRAAN HANIFF, MD, ACMC; ALICE HARDEN, SALVATION ARMY; CHRISTINE HILL, ASHTABULA CITY HEALTH DEPARTMENT; CHRIS KETTUNEN, ASHTABULA COUNTY HEALTH DEPARTMENT; DEB NEWCOMB, CONNEAUT HUMAN RESOURCE CENTER; DAVID PARKER, MD, ACMC; KATHY REGAL, COMMUNITY COUNSELING CENTER; RAYMOND SAPORITO, ASHTABULA COUNTY HEALTH DEPARTMENT; LYNN ZALEWSKI, CATHOLIC CHARITIES. ASHTABULA COUNTY MEDICAL CENTER PART V, SECTION B, LINE 7: ASHTABULA COUNTY MEDICAL CENTER CANNOT ADDRESS ALL OF THE HEALTH NEEDS PRESENT IN THE COMMUNITY. TO ENSURE ACMC REMAINS FINANCIALLY VIABLE AND IN A POSITION TO ENHANCE CURRENT SERVICES, DEVELOP NEW SERVICES AND CONTINUE TO PROVIDE A WIDE RANGE OF COMMUNITY BENEFITS, THE HOSPITAL'S IMPLEMENTATION STRATEGY FOCUS WILL NOT ADDRESS THE FOLLOWING NEEDS:DENTAL HEALTH: AS AN ACUTE CARE HOSPITAL, ACMC DOES NOT HAVE THE EXPERTISE TO ADDRESS BASIC DENTAL HEALTH.ACCIDENTS/UNINTENTIONAL INJURIES: THIS COMMUNITY HEALTH ISSUE IS BEYOND THE SCOPE OF ACMC, AND IS BEING ADDRESSED BY OTHERS.BIRTHS TO UNWED MOTHERS: THIS COMMUNITY HEALTH ISSUE IS BEYOND THE SCOPE OF ACMC, AND IS BEING ADDRESSED BY FAITH-BASED AND SOCIAL SERVICE AGENCIES.ALCOHOL ABUSE/EXCESSIVE BINGE DRINKING: THIS ISSUE IS BEYOND THE SCOPE OF ACMC AND IS BEING ADDRESSED BY OTHERS.SUICIDE: THIS COMMUNITY HEALTH ISSUE IS BEING ADDRESSED BY OTHERS, INCLUDING THE ASHTABULA COUNTY DEPARTMENT OF HEALTH AND A TASK FORCE FORMED FOLLOWING THE COMPLETION OF THE COUNTY'S COMMUNITY NEEDS ASSESSMENT.ACCESS TO HEALTHY FOODS: OTHER THAN WHAT IS OFFERED INSIDE THE WALLS OF OUR FACILITY, THIS ISSUE IS BEYOND THE SCOPE OF THE HOSPITAL AND THE HOSPITAL DOES NOT HAVE SUFFICIENT RESOURCES TO MAKE A MEANINGFUL IMPACT. ASHTABULA COUNTY MEDICAL CENTER PART V, SECTION B, LINE 20D: ALL PATIENTS ARE CHARGED THE SAME, STANDARD RATE, FOR A PARTICULAR SERVICE. ASHTABULA COUNTY MEDICAL CENTER PART V, SECTION B, LINE 22: ALL PATIENTS ARE CHARGED THE SAME, STANDARD RATE, FOR A PARTICULAR SERVICE. 5 JEFFERSON FAMILY HEALTH CENTER 234 NORTH CHESTNUT ST JEFFERSON OH 44047 FAMILY HEALTH CENTER CONNEAUT FAMILY HEALTH CENTER 354 W MAIN ROAD CONNEAUT OH 44030 FAMILY HEALTH CENTER NORTH KINGSVILLE FAMILY HEALTH CENTER 6441 S MAIN ST NORTH KINGSVILLE OH 44068 FAMILY HEALTH CENTER ASHTABULA WOMEN'S HEALTH CENTER 524 W 24TH STREET ASHTABULA OH 44004 WOMEN'S HEALTH CENTER GASTROENTEROLOGY HEALTH CENTER 2112 LAKE AVENUE ASHTABULA OH 44004 GASTROENTEROLOGY HEALTH CENTER PART I, LINE 3C: N/A PART I, LINE 6A: N/A PART I, LINE 7: ACMC ESTIMATED CHARITY CARE COSTS BY CALCULATING A RATIO OF COST TO GROSS CHARGES AND THEN MULTIPLYING THAT RATIO BY THE GROSS UNCOMPENSATED CHARGES ASSOCIATED WITH PROVIDING CARE TO CHARITY PATIENTS.ACMC IS PAID A PROSPECTIVELY DETERMINED RATE FOR THE MAJORITY OF INPATIENT ACUTE CARE AND OUTPATIENT, SKILLED NURSING, AND REHABILITATION SERVICES PROVIDED FOR MEDICAID. THESE RATES VARY ACCORDING TO A PATIENT CLASSIFICATION SYSTEM THAT IS BASED ON CLINICAL, DIAGNOSTIC, AND OTHER FACTORS. MEDICAID PAYMENTS FOR CAPITAL ARE RECEIVED ON A COST REIMBURSEMENT METHODOLOGY. PAYMENTS ARE RECEIVED ON A PROSPECTIVE BASIS FOR ACMC'S MEDICAL EDUCATION COSTS, SUBJECT TO CERTAIN LIMITS. PROVISION FOR ESTIMATED RETROACTIVE ADJUSTMENTS, IF ANY, RESULTING FROM REGULATORY MATTERS OR OTHER ADJUSTMENTS UNDER PAYMENT AGREEMENTS ARE ESTIMATED IN THE PERIOD THE RELATED SERVICES ARE PROVIDED. PART I, LINE 7G: ACMC PROVIDES AN ATHLETIC TRAINER TO THREE HIGH SCHOOLS AT NO COST TO THE SCHOOL DISTRICTS FOR THIS SERVICE. PART I, LINE 7C ACMC PARTICIPATES IN THE HOSPITAL CARE ASSURANCE PROGRAM (HCAP) TO FINANCIALLY SUPPORT THOSE HOSPITALS THAT SERVICE A DISPROPORTIONATE SHARE OF LOW-INCOME PATIENTS UNABLE TO PAY FOR CARE. HCAP FUNDS BASIC, MEDICALLY NECESSARY HOSPITAL SERVICES FOR PATIENTS WHOSE FAMILY INCOME IS AT OR BELOW THE FEDERAL POVERTY LEVEL, WHICH INCLUDES MEDICAID PATIENTS AND PATIENTS WITHOUT HEALTH INSURANCE. PART I, LINE 7E ACMC PROVIDES A SIGNIFICANT RECRUITING SUBSIDY AND GUARANTEE FOR ALL NEW PHYSICIANS THE HOSPITAL RECRUITS. IN ADDITION, THE HOSPITAL PROVIDES A GUARANTEE AFTER THE INITIAL RECRUITMENT FOR SOME PHYSICIANS DUE TO THE PRESSING NEED FOR THE PHYSICIAN'S SPECIALTY. WITHOUT THE HOSPITAL DOING THIS, ACMC WOULD NOT BE ABLE TO PROVIDE MANY OF THESE SERVICES LOCALLY. THE RECRUITMENT AND GUARANTEE COSTS ACMC INCURS REDUCES GEOGRAPHIC AND FINANCIAL BARRIERS TO ACCESSING HEALTH CARE AND IMPROVES THE AVAILABILITY OF HEALTH SERVICES IN THE AREA ACMC SERVES. PART II N/A PART III, LINE 4: TOTAL BAD DEBT EXPENSE FOR THE ENTIRE HOSPITAL COMPLEX IS EQUAL TO THE TOTAL GROSS CHARGES WRITTEN OFF AS REPORTED ON THE 2013 MEDICARE COST REPORT.PATIENT RECEIVABLES ARE REDUCED BY AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING HISTORICAL BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTHCARE COVERAGE, MAJOR PAYOR SOURCES AND OTHER COLLECTION INDICATORS. PERIODICALLY THROUGH THE YEAR, MANAGEMENT ASSESSES THE ADEQUACY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED UPON HISTORICAL WRITE-OFF EXPERIENCE BY PAYOR CATEGORY. THE RESULTS OF THIS REVIEW ARE THEN USED TO MAKE MODIFICATIONS TO THE PROVISION FOR UNCOLLECTIBLE ACCOUNTS TO ESTABLISH AN APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE RECEIVABLES. AFTER SATISFACTION OF AMOUNTS DUE FROM INSURANCE, ACMC FOLLOWS ESTABLISHED GUIDELINES FOR PLACING CERTAIN PAST-DUE PATIENT BALANCES WITH COLLECTION AGENCIES, SUBJECT TO THE TERMS OF CERTAIN RESTRICTIONS ON COLLECTION EFFORTS AS DETERMINED BY ACMC. ACMC MAINTAINS ALLOWANCES FOR LOSSES BASED ON THE EXPECTED COLLECTIBILITY OF PATIENT ACCOUNTS RECEIVABLE (BAD DEBTS) AND TO REFLECT NET AMOUNTS DUE FROM PATIENTS AND THIRD-PARTY PAYERS (CONTRACTUAL ADJUSTMENTS).ACMC PROVIDES CARE TO PATIENTS WHO DO NOT HAVE THE ABILITY TO PAY AND WHO QUALIFY FOR CHARITY SERVICES PURSUANT TO ESTABLISHED POLICIES OF ACMC. CHARITY SERVICES ARE DEFINED AS THOSE FOR WHICH PATIENTS HAVE THE OBLIGATION AND WILLINGNESS TO PAY BUT DO NOT HAVE THE ABILITY TO DO SO. ACMC DOES NOT INCLUDE CHARITY CARE IN NET PATIENT SERVICE REVENUE. PART III, LINE 8: MEDICARE SHORTFALL IS NOT TREATED AS COMMUNITY BENEFIT. THE AMOUNTS REPORTED WERE GENERATED FROM THE MEDICARE COST REPORT FILED FOR 2013. ACMC IS PAID A PROSPECTIVELY DETERMINED RATE FOR THE MAJORITY OF INPATIENT ACUTE CARE AND OUTPATIENT, SKILLED NURSING, AND REHABILITATION SERVICES PROVIDED FOR MEDICARE. THESE RATES VARY ACCORDING TO A PATIENT CLASSIFICATION SYSTEM THAT IS BASED ON CLINICAL, DIAGNOSTIC, AND OTHER FACTORS. MEDICARE PAYMENTS FOR CAPITAL ARE RECEIVED ON A PROSPECTIVE BASIS. PAYMENTS ARE RECEIVED ON A PROSPECTIVE BASIS FOR ACMC'S MEDICAL EDUCATION COSTS, SUBJECT TO CERTAIN LIMITS. ACMC IS PAID FOR COST REIMBURSABLE ITEMS AT A TENTATIVE RATE, WITH FINAL SETTLEMENT DETERMINED AFTER SUBMISSION OF ANNUAL COST REPORTS BY ACMC AND AUDITS THEREOF BY THE MEDICARE FISCAL INTERMEDIARY. PROVISION FOR ESTIMATED RETROACTIVE ADJUSTMENTS, IF ANY, RESULTING FROM REGULATORY MATTERS OR OTHER ADJUSTMENTS UNDER PAYMENT AGREEMENTS ARE ESTIMATED IN THE PERIOD THE RELATED SERVICES ARE PROVIDED.LAWS AND REGULATIONS GOVERNING MEDICARE ARE COMPLEX AND SUBJECT TO INTERPRETATION AS WELL AS SIGNIFICANT REGULATORY ACTION, AND, IN THE NORMAL COURSE OF BUSINESS, ACMC IS SUBJECT TO CONTRACTUAL REVIEWS AND AUDITS. AS A RESULT, THERE IS AT LEAST A REASONABLE POSSIBILITY THAT RECORDED ESTIMATES WILL CHANGE IN THE NEAR TERM. ACMC BELIEVES IT IS IN COMPLIANCE WITH APPLICABLE LAWS AND REGULATIONS GOVERNING THE MEDICARE PROGRAM AND THAT ADEQUATE PROVISIONS HAVE BEEN MADE FOR ANY ADJUSTMENTS THAT MAY RESULT FROM FINAL SETTLEMENTS. PART III, LINE 9B: REASONABLE EFFORTS ARE PERFORMED TO DETERMINE THE PATIENT'S ELIGIBILITY UNDER THE HOSPITAL'S FAP AND THE HOSPITAL DOES NOT PERFORM DEBT COLLECTION PROCEDURES BEFORE MAKING THESE REASONABLE EFFORTS. THIS IS ACHIEVED THROUGH THE HCAP APPLICATION. DOCUMENTATION OF THE PATIENT OR FAMILY INCOME FOR HCAP ELIGIBILITY WILL BE BASED UPON A BEST EVIDENCE METHODOLOGY. HOSPITAL EMPLOYEES WILL PROCEED THROUGH THE FOLLOWING IN AN EFFORT TO SECURE THE BEST EVIDENCE AVAILABLE FOR THE PATIENT OR GUARANTOR AT THE TIME OF THEIR ENCOUNTER. 1. A COMPLETED HCAP APPLICATION INCLUSIVE OF THE PATIENT OR GUARANTOR'S SIGNATURE. 2. A COMPLETED HCAP APPLICATION, WHICH INCLUDES THE SIGNATURE OF THE PATIENT REPRESENTATIVE SECURING THE INFORMATION FROM THE RESPONSIBLE PARTY. IF THE APPLICATION CANNOT BE SECURED AT THE TIME OF THE ENCOUNTER, THE RESPONSIBLE PARTY WILL BE PROVIDED WITH A RETURN ENVELOPE. THEY WILL BE ASKED TO PROVIDE THIS INFORMATION UPON THEIR RETURN TO THEIR HOME. IN THE EVENT THAT THE INFORMATION IS RECEIVED, IT IS TO BE REVIEWED AND CONSIDERED AGAINST THE ABOVE-DEFINED ELIGIBILITY DETERMINATION CRITERIA. IF IT IS NOT RETURNED WITHIN 14 DAYS OF DISCHARGE, ACMC CONTACTS THE PATIENT VIA TELEPHONE TO COMPLETE THE APPLICATION. FOR OUTPATIENT HOSPITAL SERVICES, THE ELIGIBILITY DETERMINATION IS EFFECTIVE FOR NINETY DAYS FROM THE INITIAL SERVICE DATE. DURING THIS PERIOD A NEW ELIGIBILITY DETERMINATION NEED NOT BE COMPLETED. ELIGIBILITY FOR INPATIENT HOSPITAL SERVICES MUST BE DETERMINED SEPARATELY FOR EACH ADMISSION , UNLESS THE PATIENT IS READMITTED WITHIN FORTY-FIVE DAYS OF DISCHARGE FOR THE SAME UNDERLYING CONDITION. ELIGIBILITY FOR RECIPIENTS OF THE DISABILITY ASSISTANCE PROGRAM MUST BE VERIFIED ON A MONTHLY BASIS. IN THE EVENT THE PATIENT DOES NOT COMPLETE AN APPLICATION DURING THE ENCOUNTER, AND AS A RESULT OF THE HCAP COMMUNICATION, PATIENT STATEMENTS, OR RESULT OF COLLECTION EFFORTS, HOSPITAL STAFF WILL COMPLETE THE HCAP APPLICATION, OVER THE TELEPHONE OR IN-PERSON, ON BEHALF OF THE RESPONSIBLE PARTY. PART VI, LINE 2: ACMC USES MARKET DATA THAT REFLECTS ACTUAL PATIENT VISITS (DATA THAT IS SUBMITTED TO THE OHIO HOSPITAL ASSOCIATION BY ALL HOSPITALS IN THE STATE). MANAGEMENT REVIEWS THE NUMBER OF PATIENTS FROM THE MARKET WHO LEAVE ASHTABULA COUNTY FOR HEALTHCARE, AND WHAT SERVICES THEY LEAVE FOR. ACMC CONDUCTS A PHYSICIAN SATISFACTION SURVEY EVERY OTHER YEAR; ONE COMPONENT OF THE SURVEY IS TO OBTAIN PHYSICIAN INPUT INTO WHAT SERVICES/SPECIALTIES ARE NEEDED. ACMC CONDUCTS A MEDICAL STAFF DEVELOPMENT PLAN (APPROXIMATELY EVERY THREE YEARS) IN WHICH COMMUNITY PHYSICIANS ARE ASKED ABOUT THEIR PRACTICE PLANS (PLANNING TO RETIRE, BECOME EMPLOYED, GO INDEPENDENT, EXPAND) AND WHAT SPECIALISTS ARE NEEDED IN THE COMMUNITY TO BETTER SERVE THEIR PATIENTS. THIS HELPS GUIDE THE PHYSICIAN RECRUITMENT EFFORTS TO ENSURE THE HOSPITAL IS MEETING THE HEALTH NEEDS OF THE MARKET. EVERYONE ON THE ADMINISTRATIVE TEAM IS ASSIGNED TO 8-12 PHYSICIANS WITH WHOM THEY HAVE REGULAR CONVERSATIONS ABOUT THEIR PRACTICE NEEDS, COMMUNITY NEEDS, ETC. MEMBERS OF THE MANAGEMENT TEAM ACTIVELY SERVE ON THE BOARDS OF COMMUNITY ORGANIZATIONS, MANY OF WHICH HAVE A MISSION TO ADDRESS COMMUNITY NEED; HEALTHCARE BEING ONE OF THOSE NEEDS (COMMUNITY ACTION, SALVATION ARMY, UNITED WAY, CATHOLIC CHARITIES, SENIOR ADVOCACY AND PROTECTIVE NETWORK, ETC.). PART VI, LINE 3: INFORMATION ABOUT ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE OR LOCAL GOVERNMENT PROGRAMS IS DESCRIBED ON THE PATIENT'S BILL, THE POLICY IS POSTED ON THE HOSPITAL'S WEBSITE AND IS ALSO AVAILABLE UPON REQUEST. THE NOTICE, BOTH IN ENGLISH AND SPANISH, IS POSTED AT THE FOLLOWING LOCATIONS: EMERGENCY DEPARTMENT, ALL ADMISSIONS/REGISTRATION AREAS, PATIENT FINANCIAL SERVICES DEPARTMENT. ACMC FINANCIAL COUNSELORS MEET WITH ANY PATIENT THAT MAY NEED ANY FORM OF FINANCIAL AID PRIOR TO DISCHARGE AND EDUCATE THEM ON FINANCIAL ASSISTANCE. PART VI, LINE 4: AFFILIATED WITH THE CLEVELAND CLINIC, ACMC IS THE LARGEST AND MOST ADVANCED HOSPITAL IN ASHTABULA COUNTY. ACMC OPENS THE DOOR TO THE WORLD'S BEST HEALTHCARE BY APPLYING CLEVELAND CLINIC'S CLINICAL INFORMATION AND STATE-OF-THE-ART STANDARDS OF CARE. THE PRIMARY MARKET IS COMPRISED OF THE FOLLOWING ZIP CODES: 44004, 44005, 44010, 44030, 44032, 44041, 44048, 44068, 44082. THE SECONDARY MARKET IS COMPRISED OF THE FOLLOWING ZIP CODES: 44003, 44076, 44084, 44085, 44093, 44099. THE PAYER MIX IS 50.8% MEDICARE, 26.90% MEDICAID, 18.9% COMMERCIAL, 2.7% SELF PAY, 0.8% OTHER. 80% OF THE MARKET HAS ONLY A HIGH SCHOOL DIPLOMA; 11% HAVE A COLLEGE DEGREE. THE MEDIAN HOUSEHOLD INCOME IS APPROXIMATELY $40,000; WITH PER CAPITA INCOME AT APPROXIMATELY $19,000. PART VI, LINE 5: ACMC IS AN ACTIVE PARTICIPANT AND SPONSOR OF EVENTS LIKE RELAY FOR LIFE AND AMERICAN HEART WALK AND SPONSOR OF HEALTH-RELATED EVENTS OF COMMUNITY ORGANIZATIONS (EXAMPLE: ZONTA WOMEN'S HEALTH DAY). ACMC PUBLISHES A COMMUNITY MAGAZINE 2X/YEAR WITH HEALTHCARE INFORMATION AND TIPS FOR HEALTHY LIVING. THE WEBSITE CONTAINS HEALTH INFORMATION AND DOWNLOADABLE RESOURCES. THE HOSPITAL HOLDS TWO WOMEN'S HEALTH LUNCHEONS EACH YEAR (HEART AND CANCER). ACMC PARTICIPATES IN NUMEROUS HEALTH FAIRS AND COMMUNITY EVENTS AT WHICH THE HOSPITAL PROVIDES FREE SCREENINGS (BLOOD PRESSURE, BLOOD SUGAR, BODY MASS INDEX, BACK STRENGTH, CHOLESTEROL). THE HOSPITAL HOLDS MONTHLY DINNER EVENTS FOR THE COMMUNITY AT WHICH A PHYSICIAN DISCUSSES SPECIFIC HEALTH ISSUES. STAFF (PHYSICIANS, CLINICIANS, ETC.) APPEAR ON LOCAL CABLE TV SHOW 2X/MONTH TO SHARE HEALTH INFORMATION. ACMC OFFERS SUPPORT GROUPS (EXAMPLES DIABETES AND COPD). THE HOSPITAL IS WORKING WITH AMERICAN CANCER SOCIETY TO OFFER REACH TO RECOVERY, LOOK GOOD FEEL BETTER AND OTHER PROGRAMS IN ASHTABULA COUNTY. ACMC ALSO PROVIDES AN ATHLETIC TRAINER TO THREE HIGH SCHOOLS (NO COST TO THE SCHOOL DISTRICTS FOR THIS SERVICE). PART VI, LINE 6: ACMC IS AN AFFILIATE OF THE CLEVELAND CLINIC. THE CLEVELAND CLINIC HEALTH SYSTEM ENGAGES IN MANY COMMUNITY OUTREACH PROGRAMS, INCLUDING INITIATIVES DESIGNED TO SERVE THE VULNERABLE AND AT-RISK POPULATIONS IN OUR COMMUNITIES. CLEVELAND CLINIC'S OUTREACH PROGRAMS RANGE FROM FREE HEALTH SCREENINGS AND CLINICAL SERVICES TO ENROLLMENT ASSISTANCE FOR GOVERNMENT-FUNDED HEALTH PROGRAMS. COMMUNITY OUTREACH PROGRAMS ARE ALSO THOSE PROGRAMS THAT IMPROVE ACCESS TO HEALTH SERVICES. CLEVELAND CLINIC CAREGIVERS COLLABORATE WITH COMMUNITY ORGANIZATIONS TO PROVIDE A CONTINUUM OF CARE THAT SUPPORTS ECONOMICALLY AND MEDICALLY UNDERSERVED AREAS. THE 2013 COMMUNITY BENEFIT REPORT PUBLISHED BY THE CLEVELAND CLINIC STATED $652.7 MILLION WAS SPENT BY THE CLEVELAND CLINIC IN 2013 ON COMMUNITY OUTREACH PROGRAMS. PART VI, LINE 7 N/A X X X 0 0 0 0 0 0 0 0 0 JUDE CAUWENBERGH DO BOARD MEMBER/PHYSICIAN REP 290063 0 0 0 270 0 6560 0 3578 0 300471 0 0 0 SUK K CHOI MD BOARD MEMBER/PHYSICIAN REP 703415 0 0 0 1219 0 10200 0 6165 0 720999 0 0 0 ROBERT DLWGOSH MD BOARD MEMBER/PHYSICIAN REP 408200 0 0 0 774 0 6400 0 6874 0 422248 0 0 0 ALEXANDER TAICH MD PHYSICIAN 795300 0 0 0 17662 0 10200 0 502 0 823664 0 0 0 JAMES CHILLCOTT MD PHYSICIAN 612461 0 0 0 18017 0 10200 0 6891 0 647569 0 0 0 LAXMAN R CINGIREDDI MD PHYSICIAN 555975 0 0 0 17770 0 8619 0 4372 0 586736 0 0 0 YISA B SUNMONU MD PHYSICIAN 512564 0 0 0 17770 0 10200 0 6372 0 546906 0 0 0 MICHAEL J PAPSIDERO MD PHYSICIAN 488969 0 0 0 1188 0 10200 0 6149 0 506506 0 0 0 PART I, LINE 3 SALARIES ARE REVIEWED APPROXIMATELY EVERY TWO YEARS. SALARIES ARE COMPARED TO LOCAL, REGIONAL, AND NATIONAL MARKET RATES AND IN CONJUNCTION WITH THE CEO AND CFO TO DETERMINE COMPENSATION. WHEN OPENINGS FOR KEY POSITIONS BECOME AVAILABLE, THE HR DEPARTMENT EXAMINES THE MARKET RATES TO DETERMINE A STARTING SALARY. EVERY YEAR THE TYPICAL SALARY HAS A 2% MERIT RATE INCREASE. ASHOK KONDRU MD BOARD TRUSTEE & EMPLOYEE OF ACMC; SPOUSE IS ON BOARD - NAFISA KONDRU PART OF EMPLOYMENT AGREEMENT. REPAYMENT BEGINS IN 2014. X 150000 150000 0 1 1 150000 KONDRU INVESTMENTS LTD ENTITY OWNED BY ASHOK KONDRU & SPOUSE OF NAFISA KONDRU, ACMC TRUSTEES 341299 IN 2013, ASHTABULA COUNTY MEDICAL CENTER (ACMC) PURCHASED THE MEDICAL PRACTICE OF ASHOK KONDRU, M.D. THE BUILDING OF THE MEDICAL PRACTICE WAS PURCHASED FOR $325,000 AND PAID TO KONDRU INVESTMENTS LTD, AN ENTITY OWNED BY ASHOK KONDRU, M.D. THE SALES PRICE WAS BASED ON AN INDEPENDENT VALUATION PREPARED BY A THIRD PARTY ENGAGED BY ACMC.ACMC ALSO PAID 4 MONTHS OF RENT TO KONDRU INVESTMENTS LTD. OF $16,299 AS ACMC PLACED ANOTHER PHYSICIAN IN THE BUILDING PRIOR TO THE PURCHASE OF THE BUILDING OCCURING. 0 ASHOK KONDRU INC ENTITY OWNED BY ASHOK KONDRU & SPOUSE OF NAFISA KONDRU, ACMC TRUSTEES 221408 IN 2013, ACMC PURCHASED THE MEDICAL PRACTICE OF ASHOK KONDRU, M.D. ACMC PAID $94,408 FOR THE EQUIPMENT AND $127,000 FOR THE CHARTS & RECORDS AND PAID TO ASHOK KONDRU, INC., AN ENTITY OWNED BY ASHOK KONDRU, M.D. THE SALES PRICE WAS BASED ON AN INDEPENDENT VALUATION PREPARED BY A THIRD PARTY ENGAGED BY ACMC. 0 KIMBERLY GIANGOLA FAMILY MEMBER OF JOSEPH GIANGOLA, ACMC TRUSTEE 19741 EMPLOYMENT AGREEMENT WITH ACMC 0 BRITTANY COACH FAMILY MEMBER OF PEG CARLO, ACMC TRUSTEE 54462 EMPLOYMENT AGREEMENT WITH ACMC 0 JENINE ENGLISH FAMILY MEMBER OF PEG CARLO, ACMC TRUSTEE 69270 EMPLOYMENT AGREEMENT WITH ACMC 0 JENNIFER CAUWENBERGH FAMILY MEMBER OF JUDE CAUWENBERGH, D.O., ACMC TRUSTEE 24088 EMPLOYMENT AGREEMENT WITH ACMC 0 KIM COXEN FAMILY MEMBER OF JEFF COXEN, ACMC TRUSTEE 30983 EMPLOYMENT AGREEMENT WITH ACMC 0 FORM 990, PART VI, SECTION A, LINE 2 ASHOK KONDRU, M.D. IS THE SPOUSE OF NAFISA KONDRU, M.D. BOTH ARE BOARD TRUSTEES. FORM 990, PART VI, SECTION A, LINE 3 THE CLEVELAND CLINIC FOUNDATION HOLDS AND EXERCISES A MANAGEMENT AGREEMENT WITH ACMC. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 REPORT IS PUBLISHED TO THE BOARD OF DIRECTOR'S WEBSITE. FORM 990, PART VI, SECTION B, LINE 12C ALL OFFICERS, TRUSTEES, AND KEY EMPLOYEES ARE REQUIRED TO ANNUALLY REVIEW AND SIGN A CONFLICT OF INTEREST POLICY ACKNOWLEDGEMENT FORM. FORM 990, PART VI, SECTION B, LINE 15 SALARIES ARE REVIEWED APPROXIMATELY EVERY TWO YEARS. SALARIES ARE COMPARED TO LOCAL, REGIONAL, AND NATIONAL MARKET RATES AND IN CONJUNCTION WITH THE CEO AND CFO TO DETERMINE COMPENSATION. WHEN OPENINGS FOR KEY POSITIONS BECOME AVAILABLE, THE HR DEPARTMENT EXAMINES THE MARKET RATES TO DETERMINE A STARTING SALARY. EVERY YEAR THE TYPICAL SALARY HAS A 2% MERIT RATE INCREASE. FORM 990, PART VI, SECTION C, LINE 19 ALL REQUESTS ARE SENT TO THE CEO FOR DISTRIBUTION. FORM 990, PART VII, SECTION A THE FOLLOWING OFFICERS WORKING FULL-TIME FOR ACMC ARE EMPLOYED BY THE CLEVELAND CLINIC AND ARE COMPENSATED THROUGH EMPLOYMENT AGREEMENTS WITH THE CLEVELAND CLINIC: MICHAEL HABOWSKI, PRESIDENT/CEO AND DON KEPNER, VP FINANCE/CFO. FORM 990, PART XI, LINE 9: EQUITY INCOME IN AFFLIATE 185,665. INTERCOMPANY NET ASSET TRANSFER FROM ROCK CREEK MEDICAL CENTER 6,961,649. DISTRIBUTION TO CLEVELAND CLINIC FOUNDATION -2,364,250. EFFECT OF RECOGNITION PROVISION AT MEASUREMENT DATE OF PENSION OBLIGATION 10,718,662. ASHTABULA COUNTY MEDICAL CENTER FOUNDATION 2420 LAKE AVENUE ASHTABULA OH 44004 341392784 SUPPORT THE ASHTABULA COUNTY MEDICAL CENTER OH 501(C)(3) LINE 11A, I ASHTABULA COUNTY MEDICAL CENTER 0 ROCK CREEK MEDICAL CENTER DBA GLENBEIGH HEALTH SOURCES 2863 STATE ROUTE 45 ROCK CREEK OH 44084 341789783 OPERATE AND MAINTAIN A HOSPITAL AND OUTPATIENT CENTERS OH 501(C)(3) LINE 3 ASHTABULA COUNTY MEDICAL CENTER 0 ASHTABULA REGIONAL HOME HEALTH SERVICES 3949 JEFFERSON ROAD ASHTABULA OH 44004 341143158 HOME HEATH SERVICES OH 501(C)(3) LINE 9 ASHTABULA COUNTY MEDICAL CENTER 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 ASHTABULA COUNTY MEDICAL CENTER FOUNDATION C 99140 CASH RECEIVED ASHTABULA COUNTY MEDICAL CENTER FOUNDATION Q 84329 CASH RECEIVED ROCK CREEK MEDICAL CENTER DBA GLENBEIGH HEALTH SERVICES Q 136129 CASH RECEIVED ASHTABULA REGIONAL HOME HEALTH SERVICES Q 160427 CASH RECEIVED