2014-01-15T12:27:22-06:00 2013-06-30 621046406 JOHNSON HICKEY & MURCHISON PC 651 E 4TH ST STE 200 CHATTANOOGA TN 37403 990 2012-07-01 620790132 CUMBERLAND MEDICAL CENTER CUMB 9314849511 421 SOUTH MAIN STREET CROSSVILLE TN 38555 LARRY E MOORE 9314849511 2014-01-17 BARRY R HUGGINS P00627334 4237560052 2012 2016-02-25 16:41:14Z LARRY E MOORE 421 SOUTH MAIN STREET CROSSVILLE TN 38555 104592254 0 X WWW.CMCHEALTHCARE.ORG X 1967 TN THE MISSION IS TO MAKE AVAILABLE QUALITY HEALTH CARE ON A REGIONAL LEVEL TO THOSE IN NEED OF ITS SERVICE THROUGH DEDICATION, PROFESSIONALISM AND FINANCIAL STABILITY. 10 5 1285 143 0 0 161654 67721 106710289 100950037 338109 302817 429889 3271679 107639941 104592254 0 0 0 0 51592457 50625449 0 0 0 54007621 54539082 105600078 105164531 2039863 -572277 124330508 123037648 52937183 51172605 71393325 71865043 X THE MISSION IS TO MAKE AVAILABLE QUALITY HEALTH CARE ON A REGIONAL LEVEL TO THOSE IN NEED OF ITS SERVICE THROUGH DEDICATION, PROFESSIONALISM AND FINANCIAL STABILITY. 0 0 8560297 19601837 INPATIENT ROUTINE CARE SERVICES TO INCLUDE NURSING, MEALS, HOUSEKEEPING, ETC. FOR 22,652 ROUTINE INPATIENT DAYS. 6508226 26835163 CUMBERLAND MEDICAL CENTER PERFORMED 10,003 SURGICAL PROCEDURES. 4702272 18066613 CUMBERLAND MEDICAL CENTERS DISPENSED 859,652 PHARMACY DOSES. 73013172 39721269 ALL OTHER ROUTINE AND NECESSARY EXPENSES TO PROVIDE HEALTHCARE SERVICES IN AN ACUTE CARE HOSPITAL WITH 145 ROUTINE BEDS, 12 INTENSIVE CARE UNIT BEDS, 14 NURSERY BEDS, AND 12 REHABILITATION UNIT BEDS. 73013172 39721269 92783967 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 76 0 1 1285 1 0 0 0 0 0 0 0 0 0 0 X 10 5 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 TN X LARRY MOORE CFO 9314849511 421 S MAIN STREET CROSSVILLE TN 38555 REYNALDO OLAECHEA 40.00 X 176434 0 12673 BETH PETTY MD 0.00 X 0 0 0 COSBY A STONE 0.00 X X 0 0 0 JW BROWN 0.00 X X 0 0 0 JAMES BARNAWELL MD 40.00 X X 323554 0 0 SALLY OGLESBY 0.00 X X 0 0 0 LARRY REED MD 40.00 X 17100 0 0 ED CAMERA 0.00 X 0 0 0 ROY HOWARD 0.00 X 0 0 0 ROBERT HARRISON 0.00 X X 0 0 0 LARRY MOORE 40.00 X 250925 0 2328 SIVALINGAM KANAGASEGAR MD 40.00 X 334949 0 18536 ERNEST M MAK MD 40.00 X 271046 0 13373 ELIS ABOU-ZEID MD 40.00 X 261816 0 7376 LANA JERADEH-BOURSOULIAN MD 40.00 X 246336 0 12194 JAMES S JOHNSON MD 40.00 X 273055 0 18536 BARRY S WAGNER MD 40.00 X 154855 0 2391 2310070 0 87407 29 1 1 0 CUMBERLAND ANESTHESIA GROUP LLC PO BOX 88544 MILWAUKEE WI 53288 CONTRACT ANESTHESIA 1178483 JAMES BARNWELL MD 421 SOUTH MAIN STREET CROSSVILLE TN 38555 PATHOLOGY 323354 MOBILE TECH SVC 201 NORTH WHITE 1 ATHENS TN 37303 MOBILE PET/CT 320450 DR JOHN MILLIGAN 61 FLAMINGO DRIVE CROSSVILLE TN 38555 PROFESSIONAL LIABILITY INS./PHYSICIANS G 305279 BIO-MEDICAL APPLICATIONS OF TN PO BOX 101518 ATLANTA GA 30392 SOFTWARE 196975 9 66721 1000 67721 NET PATIENT SERVICE REVENUE 621990 100950037 100950037 100950037 299651 299651 362617 0 362617 362617 362617 3166 0 3166 3166 3166 ELECTRONIC HEALTH RECORD INCENTIV 621990 2718441 2718441 MISCELLANEOUS REVENUE 621990 190621 190621 2909062 104592254 104224882 0 299651 489538 489538 40543400 33236680 7306720 350198 283660 66538 6393152 5178453 1214699 2849161 2307820 541341 1959049 1586830 372219 63696 51594 12102 48392 48392 7003838 7003838 1397274 1397274 201837 201837 119073 119073 4157768 3367792 789976 150496 121902 28594 2029669 2029669 6236072 6236072 2488615 2488615 MEDICAL SUPPLIES AND DR 11830183 11830183 BAD DEBTS 8902360 8902360 TAX & LICENSES 4022848 3258507 764341 OTHER EXPENSES 2796738 2247742 548996 1131174 885674 245500 105164531 92783967 12380564 0 22024303 7108019 3527767 3738871 15869091 14199111 1882 254856 1735459 1885539 1086211 1037672 152226133 74137105 76895440 78089028 805510 210761 2384845 16513791 124330508 123037648 8081655 7482198 40138718 40017750 4716810 3672657 52937183 51172605 X 71231631 71717738 161694 147305 71393325 71865043 124330508 123037648 X -572277 1043995 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2754819 2754819 87196328 29950583 57245745 58426234 43244364 15181870 3848752 942158 2906594 78089028 BOND ISSURANCE COSTS 49779 GOODWILL 533392 OTHER ASSETS 740517 ASSETS INTERNALLY DESIGNATED FOR CAPITAL IMPROVEMENTS 15042798 CASH LIMITED TO SPECIAL OPERATIONS 82299 INVESTMENTS FOR SPECIAL PROJECTS 65006 16513791 SWAP AGREEMENT LIABILITY 3247413 CMC CAPITAL LEASE LIABILITY 402336 CMC MOB SECURITY DEPOSITS 22908 3672657 X 105636249 1043995 1043995 104592254 0 104592254 105164531 0 105164531 0 105164531 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE MEDICAL CENTER ACCOUNTS FOR UNCERTAIN TAX POSITIONS WITH PROVISIONS OF FASB ASC 740-10 "ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES." ASC 740-10 PROVIDES GUIDANCE ON DERECOGNITION OF TAX BENEFITS, CLASSIFICATION ON THE BALANCE SHEET, INTEREST AND PENALTIES, ACCOUNTING IN INTERIM PERIODS, DISCLOSURE AND TRANSITION. THE MEDICAL CENTER BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. AS OF JUNE 30, 2013 AND 2012, THE MEDICAL CENTER DID NOT RECORD ANY INTEREST OR PENALTIES ASSOCIATED WITH UNCERTAIN TAX POSITIONS THE MEDICAL CENTER'S FORM 990, RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX, FOR THE YEARS 2010 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE IRS, GENERALLY FOR THREE YEARS AFTER THEY WERE FILED. PART XI, LINE 2D - OTHER ADJUSTMENTS: UNREALIZED GAIN ON SWAP AGREEMENT 1,125,300. UNREALIZED LOSSES ON OTHER THAN TRADING SECURITIES -22,501. EXCESS OF CONSIDERATION PAID IN EXCESS OF VALUE IN ACQUISITION -66,162. CHANGE IN RESTRICTED ASSETS 7,358. 1 1 1 X 1 X 1 1 1 0 0 608289 608289 0.00630 12659932 6084910 6575022 0.06830 13268221 6084910 7183311 0.07460 553784 1548 552236 0.00570 6349423 4691553 1657870 0.01720 29890 29890 0.00030 6933097 4693101 2239996 0.02320 20201318 10778011 9423307 0.09780 1 8902360 3203861 37828042 36646164 1181878 X 1 1 1 CST COMM HEALTH LLC HEALTHCARE SERVICES/CARDIAC CATH 1.00000 1 1 CUMBERLAND MEDICAL CENTER INC

421 S MAIN ST CROSSVILLE TN 38555

X X X HOSPITAL CUMBERLAND MEDICAL CENTER 1 1 X X X X X X X X X 12 1 0 0 X X X X X X X X 1 0 1 1 150.000000000000 1 200.000000000000 1 X X X X X X X 1 1 X X X X X 1 X X 1 X X X X X X 1 0 0 10 CMC HOME CARE

79 S MAIN ST CROSSVILLE TN 38555

HOME HEALTH AGENCY CUMBERLAND PHYSICAL REHAB UNIT

421 S MAIN ST CROSSVILLE TN 38555

INPATIENT REHABILITATION FACILITY CUMBERLAND PHYSICIANS GROUP

133 HAYES ST CROSSVILLE TN 38555

GEN. AND SPECIALTY PHYSICIANS CMC WELLNESS COMPLEX

130 WOODMERE MALL CROSSVILLE TN 38555

WELLNESS AND DIABETES MANAGEMENT CUMBERLAND MEDICAL CENTER AT FFG

130 STONEHENGE DR CROSSVILLE TN 38555

WELLNESS, PHYSICAL THERAPY, & MAMMOGRAPHY CMC OUTPATIENT IMAGING CENTER

28 HAYES ST CROSSVILLE TN 38555

MEDICAL IMAGING AND PET SCAN CMC MEDICAL EQUIPMENT SERVICES

591 S MAIN ST CROSSVILLE TN 38555

MEDICAL EQUIPMENT AND OXYGEN CMC CANCER CENTER

421 S MAIN ST CROSSVILLE TN 38555

ONCOLOGY RADIATION THERAPY CMC OCCUPATIONAL MEDICINE

44 HAYES ST SUITE 202 CROSSVILLE TN 38555

WORK RELATED CARE AND EXAMS CMC WOUND CENTER

421 S MAIN ST CROSSVILLE TN 38555

WOUND AND HYPERBARIC TREATMENT PART I, LINE 7: LINE 7E - COMMUNITY HEALTH IMPROVEMENT AND BENEFIT OPERATIONSTHE COST OF $552,236 FOR COMMUNITY HEALTH IMPROVEMENT AND BENEFIT OPERATIONS WAS PROVIDED BY VARIOUS OPERATIONS INCLUDING:BLOOD PRESSURE CHECKS AND VARIOUS VOLUNTEER SERVICES AT THE SENIOR CITIZEN CENTERSERVICES PROVIDED TO THE BREAD OF LIFE MISSION CLINICRELAY FOR LIFE AND HEART WALKCOLON CANCER SCREENING AND CONSULTATIONGRIEF AND CPAP SUPPORT GROUPSPROVIDING COMMUNITY HEALTH FAIRSPROVIDING MEDICAL EDUCATION SEMINARS PART I, LINE 7G: SUBSIZIDED HEALTH SERVICESTHE SUBSIDY OF $1,657,870 IS THE DIFFERENCE BETWEEN THE COST OF SERVICES PROVIDED IN THE HOSPITAL'S PHYSICIAN OFFICES, WOUND CARE CENTER, AND SENIOR PERSPECTIVES AND THE PAYMENTS RECEIVED FOR THOSE SERVICES. THE PHYSICIAN OFFICES INCLUDE FAMILY, INTERNAL MEDICINE, OB/GYN, SURGEONS, AND OTHER SPECIALTY PHYSICIANS. ALTHOUGH PATIENTS WITH MEDICARE OR COMMERCIAL INSURANCE COVERAGE ARE PROVIDED SERVICES, THESE PHYSICIAN OFFICES WERE ESTABLISHED TO PROVIDE SERVICES FOR PATIENTS WITHOUT INSURANCE COVERAGE OR WITH TENNCARE/MEDICAID. THE COST OF PROVIDING THESE SERVICES EXCEEDED THE PAYMENTS RECEIVED BY $1,505,872 DURING THE REPORTING PERIOD.THE WOUND CARE CENTER PROVIDES HYPERBARIC AND WOUND TREATMENT SERVICES. THE COST OF PROVIDING SERVICES EXCEEDED REVENUE BY $176,199 SENIOR PERSPECTIVES PROVIDES BEHAVIORAL HEALTH SERVICES TO SENIOR CITIZENS. REVENUE FOR THESE SERVICES EXCEEDED THE COST RECEIVED BY $14,327 DURING THE REPORTING PERIOD. 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 $ 8902360. PART III, LINE 4: THE MEDICAL CENTER MAINTAINS ALLOWANCES FOR DOUBTFUL ACCOUNTS FOR ESTIMATED LOSSES RESULTING FROM THE INABILITY OF ITS PATIENTS TO MAKE PAYMENTS. MANAGEMENT CONSIDERS THE FOLLOWING FACTORS WHEN DETERMINING THE COLLECTIBILITY OF PATIENT ACCOUNTS: PAYOR CREDIT-WORTHINESS, PAST TRANSACTION HISTORY WITH THE PAYOR, CURRENT ECONOMIC INDUSTRY TRENDS, AND CHANGES IN PAYOR PAYMENT TERMS. IF THE FINANCIAL CONDITION OF THE MEDICAL CENTER'S PAYORS OR PATIENTS WERE TO DETERIORATE, ADVERSELY AFFECTING THEIR ABILITY TO MAKE PAYMENTS, ADDITIONAL ALLOWWANCES WOULD BE REQUIRED. BASED ON MANAGEMENT'S ASSESSMENT, THE MEDICAL CENTER PROVIDES FOR ESTIMATED UNCOLLECTABLE AMOUNTS THROUGH A CHARGE TO EARNINGS AND A CREDIT TO AN ALLOWANCE. BALANCES THAT REMAIN OUTSTANDING AFTER THE MEDICAL CENTER HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE ALLOWANCE AND A CREDIT TO ACCOUNTS RECEIVABLE.THE ESTIMATED AMOUNT OF THE MEDICAL CENTER'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS 7.2% OF THE TOTAL BAD DEBT EXPENSE. THIS IS BASED ON THE PERCENT OF THE POPULATION IN CUMBERLAND COUNTY IN 2010 THAT IS LIVING IN POVERTY (SOURCE HTTP://WWW.ERS.USDA.GOV/DATA-PRODUCTS/COUNTY-LEVEL-DATA-SETS/POVERTY.ASPX). SINCE THE MEDICAL CENTER PROVIDES FINANCIAL ASSISTANCE TO THOSE WHO EXCEED THE FEDERAL POVERTY LEVEL BY 150 - 200%, THIS PERCENT IS A CONSERVATIVE ESTIMATE. PART III, LINE 8: CUMBERLAND MEDICAL CENTER IS AN ACUTE CARE MEDICAL/SURGICAL FACILITY WHICH SERVES A LARGE TENNCARE AND MEDICARE POPULATION. WITH THIS DEMOGRAPHIC COMES THE REALIZATION OF LOW REIMBURSEMENT, BAD DEBT, AND MEDICARE SHORTFALLS. IN OUR AREA OF THE COUNTRY AND ESPECIALLY OUR AREA OF THE STATE, IT IS PART OF PROVIDING HEALTHCARE TO OUR PATIENTS. WE CONSIDER A LARGE PART OF WHAT WE "WRITE-OFF" EACH YEAR AND THE MONEY THAT WE WILL NEVER SEE AS INCOME TO OUR BOTTOM LINE AS A BENEFIT THAT WE GIVE BACK TO OUR COMMUNNITY. IT IS A SERVICE THAT WE ARE PROVIDING TO THOSE WHO CANNOT PROVIDE FOR THEMSELVES. OUR MISSION STATES THAT WE WILL MAKE AVAILABLE QUALITY HEALTH CARE ON A REGIONAL LEVEL TO THOSE IN NEED OF ITS SERVICES THROUGH DEDICATION, PROFESSIONALISM, AND FINANCIAL STABILITY. WHILE IT IS OUR FIDUCIARY RESPONSIBILITY TO MANAGE OUR FACILITY, IT IS OUR FIRST CONCERN TO CARE FOR THE PATIENT'S HEALTH AND WELL BEING. THE DIFFERENCE BETWEEN THOSE IN A COMMUNITY LIKE OURS WHEN ABSORBED BY THE HOSPITAL IS MOST DEFINITELY BENEFITTING THE COMMUNITY. X X X 0 0 0 1 0 1 0 0 0 REYNALDO OLAECHEA 176434 0 0 0 0 0 1750 0 10923 0 189107 0 0 0 JAMES BARNAWELL MD 323554 0 0 0 0 0 0 0 0 0 323554 0 0 0 LARRY MOORE 250925 0 0 0 0 0 1360 0 968 0 253253 0 0 0 SIVALINGAM KANAGASEGAR MD 334949 0 0 0 0 0 2450 0 16086 0 353485 0 0 0 ERNEST M MAK MD 271046 0 0 0 0 0 2450 0 10923 0 284419 0 0 0 ELIS ABOU-ZEID MD 261816 0 0 0 0 0 591 0 6785 0 269192 0 0 0 LANA JERADEH-BOURSOULIAN MD 246336 0 0 0 0 0 622 0 11572 0 258530 0 0 0 JAMES S JOHNSON MD 273055 0 0 0 0 0 2450 0 16086 0 291591 0 0 0 BARRY S WAGNER MD 154855 0 0 0 0 0 1544 0 847 0 157246 0 0 0 PART I, LINE 5 COMPENSATION CONTINGENT UPON REVENUES OF ORGANIZATION: LISTED EMPLOYED PHYSICIANS RECEIVE AN INCENTIVE BONUS EQUAL TO A PERCENTAGE OF CASH COLLECTIONS FROM THEIR OWN PRACTICE GREATER THAN THE PHYSICIAN'S ANNUAL SALARY. PART I, LINE 6 PAID COMPENSATION CONTINGENT ON THE NET EARNINGS OF THE ORGANIZATION: THE PRESIDENT/CEO AND OTHER OFFICERS RECEIVE AN INCENTIVE BONUS BASED ON VARIOUS CRITERIA, INCLUDING A COMPARISON OF ACTUAL NET EARNINGS TO BUDGETED NET EARNINGS. A HEALTH & ED FAC BD OF THE CITY OF CROSSVILLE TN REV REFUND BONDS SER 2012 581799575 2012-05-01 40017750 PAYOFF PREVIOUSLY ISSUED BONDS 0 0 0 A 39967221 40017750 50529 2012 0 0 1 1 A 0 0 0 0 0 0 0 A 0 0 1 0 1 1 REGIONS BANK 5.000000000000 1 0 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 MANAGEMENT AND THE BOARD OF DIRECTORS WILL REVIEW THE 990 BEFORE IT IS FILED. FORM 990, PART VI, SECTION B, LINE 12C CUMBERLAND MEDICAL CENTER'S CONFLICT OF INTEREST STATEMENT IS DISCUSSED AND REVIEWED WITH POTENTIAL APPLICANTS FOR EMPLOYMENT DURING THE INTERVIEW PROCESS, WITH NEW EMPLOYEES DURING A NEW EMPLOYEE ORIENTATION AS WELL AS DURING DEPARTMENTAL ORIENTATION AND ANNUALLY FOR ALL EMPLOYEES DURING EACH EMPLOYEE'S ANNUAL PERFORMANCE REVIEW. IF NO CONFLICT OF INTEREST IS IDENTIFIED, IT IS NOTED ON THE CONFLICT OF INTEREST STATEMENT, SIGNED BY THE EMPLOYEE, AND PLACED IN THE EMPLOYEE'S FILE. IF A CONFLICT OF INTEREST IS IDENTIFIED, AFTER DISCUSSION AND REVIEW BY A CORPORATE OFFICER AND/OR OTHER ADDITIONAL INPUT AS NECESSARY, APPROPRIATE ACTION IS TAKEN UP TO AND INCLUDING TERMINATION OF EMPLOYMENT WITH CUMBERLAND MEDICAL CENTER OR THE OTHER EMPLOYER THAT IS CAUSING THE CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 THE CEO REVIEW COMMITTEE AND THE EXECUTIVE COMPENSATION COMMITTEE REVIEW THE PERFORMANCE AND SALARY OF THE CEO ANNUALLY. THE COMMITTEES ARE APPOINTED ANNUALLY BY THE CHAIRMAN OF THE BOARD OF DIRECTORS. TENNESSEE HOSPITAL ASSOCIATION SALARY SURVEY INFORMATION IS PROVIDED FOR REVIEW. DUE TO BUDGET CONSTRAINTS, NO WAGE INCREASE WAS PROVIDED DURING THE YEAR. THE PRESIDENT/CEO REVIEWS THE PERFORMANCE AND SALARY OF THE OFFICERS. TENNESSEE HOSPITAL ASSOCIATION SALARY SURVEY INFORMATION IS PROVIDED FOR REVIEW. DUE TO BUDGET CONSTRAINTS, NO WAGE INCREASES FOR OFFICERS WERE PROVIDED DURING THE YEAR. FORM 990, PART VI, SECTION C, LINE 19 NO DOCUMENTS AVAILABLE TO THE PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: UNREALIZED GAIN ON SWAP AGREEMENT 1,125,300. UNREALIZED LOSS ON OTHER THAN TRADING SECURITIES -22,501. NET CHANGE IN TEMPORARILY RESTRICTED ASSETS -21,748. EXCESS OF CONSIDERATION PAID FOR ACQUISITION -66,162. NET ASSETS RELEASED FROM RESTRICTIONS 21,748. OTHER CHANGES IN ASSETS 7,358.