2014-05-13T07:10:11-05:00 2013-06-30 550486667 Arnett Foster Toothman PLLC P O Box 2629 Charleston WV 25329 990 2012-07-01 550477361 Boone Memorial Hospital Inc BOON 3043691230 701 Madison Avenue Madison WV 25130 Tommy H Mullins 3043691230 2014-05-09 1 Dale Carpenter P00189642 3043460441 2012 2015-11-30 17:44:51Z X Tommy H Mullins 701 Madison Avenue Madison WV 25130 26064837 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 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 9 224 36 0 0 67656 108186 24937415 25303619 98146 300371 286373 352661 25389590 26064837 89750 119300 0 8335071 9677958 0 0 15874751 16399980 24299572 26197238 1090018 -132401 10950054 10933595 4038314 4154256 6911740 6779339 X The basic mission of Boone Memorial Hospital is to create an environment in which qualified physicians and other health care personnel can work together to provide high quality health care service, in an atmosphere of brotherly love and concern, to the residents of Boone County and surrounding areas. 0 0 22722827 119300 25290034 In performing its mission, Boone Memorial Hospital had 438 acute care admissions and 123 skilled nursing care admissions. The Hospital also had 60 respite care patients, 12,727 emergency room visits, 20,020 out-patient visits and 21,212 visits in its two rural health clinics. 4174 13585 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. BMH Respite Care Program and All About Health. The Hospital had 60 respite care admissions and 1,376 respite days for its 6/30/13 fiscal year.Revenue and expenses related to these services are included above in box 4a. 22727001 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 1 0 0 0 0 0 0 0 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 34 0 1 224 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 0 1 1 1 0 1 0 X Randell D Foxx 3043691230 701 Madison Avenue Madison WV 25130 Robert Brown 1.30 X 0 0 0 James Hensley 1.30 X 0 0 0 Janey Yeager 1.30 X 0 0 0 Thomas Bias 1.30 X 0 0 0 Douglas Bell 1.30 X 0 0 0 William Stone 1.30 X 0 0 0 Virgil Underwood 1.30 X 0 0 0 James Gore 1.30 X 0 0 0 Kip Howell 1.30 X 0 0 0 Tommy H Mullins 40.00 X 135405 0 95820 Randell D Foxx 40.00 X 100238 0 18273 Ziad Chanaa 40.00 X 147765 0 78908 Kevin Hill 40.00 X 141000 0 15638 524408 0 208639 2 0 1 0 Rehab One Ltd 1834 Park Avenue Belle WV 25015 Physical Therapy Services 956060 CPSI PO Box 850309 Mobile AL 36685 System Software Vendor 911439 Pharmacy Management & Consulting Service 928 Helene Street St Albans WV 25177 Pharmacy services 598735 Chester J Yanik & Associates 4400 Shoreline Drive Spring Park MN 55384 Architects 428747 CAMC Labworks PO Box 388 Charleston WV 25323 Lab services 398355 20 65252 42934 108186 Patient Service Revenue 624100 25303619 25303619 25303619 56896 56896 175 0 175 175 175 243475 0 243475 243475 243475 Health fair 900099 116846 116846 Pharmacy 446110 99182 99182 Dietary sales 722210 50460 50460 85998 85998 352486 26064837 25303619 0 653032 X 119300 119300 367893 281070 86823 7185473 5489701 1695772 79251 60548 18703 1478105 1129272 348833 567236 433368 133868 14664 14664 6148528 5847787 300741 75931 75931 1710861 1307098 403763 296631 226626 70005 203398 155396 48002 17879 13660 4219 38510 29422 9088 25108 19183 5925 535721 409291 126430 355691 271748 83943 Bad debt expense 5502902 5502902 0 Medical supplies 851464 851464 0 Provider tax 439067 439067 0 Dues and subscriptions 64229 49071 15158 119396 91027 28369 26197238 22727001 3470237 0 2138556 1973903 3095217 2159761 1992659 2207520 184922 111037 245749 256944 78670 31837 9948850 6926082 1929761 3022768 251644 258940 822465 910885 210411 10950054 10933595 2459494 2498618 55266 392 572368 419897 951186 1235349 4038314 4154256 X 6911740 6779339 6911740 6779339 10950054 10933595 -132401 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 216178 216178 1433236 1206406 226830 6677722 5631077 1046645 1621714 88599 1533115 3022768 Other investment securities 910885 C 910885 Deferred compensation 989097 Third party payor settlements 246252 1235349 20561935 0 20561935 5502902 5502902 26064837 20694336 0 20694336 5502902 5502902 26197238 Part XI, Line 4b - Other Adjustments: Bad debt expense netted with revenue on financial statements 5,502,902. Part XII, Line 4b - Other Adjustments: Bad debt expense netted with revenue on financial statements 5,502,902. 1 1 X 1 X 1 X 0 1 1 0 0 617471 1163735 -546264 0.00000 3408592 3916687 -508095 0.00000 4026063 5080422 -1054359 4026063 5080422 -1054359 15 5606 5606 0.00030 15 5606 5606 0.00030 1 2491164 4987213 4522909 464304 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 X X 1 0 1 1 200.000000000000 1 200.000000000000 1 X X X X X 1 1 X X X 1 0 X X X 1 X 0 0 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 $ 5502902. Part II: 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. 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 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 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 publisize 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 2 36499 Cash - FMV Student loan assistance to professional employees X 0 1 0 0 0 0 0 0 0 Tommy H Mullins 135405 0 0 0 0 0 87159 0 11265 0 233829 0 0 0 Ziad Chanaa 147765 0 0 0 0 0 66000 0 12908 0 226673 0 0 0 Kevin Hill 141000 0 0 0 0 0 2730 0 13998 0 157728 0 0 0 Part I, Line 4b Tommy H. Mullins, CEO, participated in a 457(f) plan during 2013. Form 990, Part VI, Section B, line 11 Randy Foxx, CFO will review the Form 990 for accuracy prior to filing with the IRS. A copy of the final Form 990 will be provided to the Board of Directors prior to filing with the IRS. Form 990, Part VI, Section B, line 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. Other Fees Form 990, Part IX, line 11g Surgery: Program service expenses 270,147. Management and general expenses 0. Fundraising expenses 0. Total expenses 270,147. Radiology: Program service expenses 433,525. Management and general expenses 0. Fundraising expenses 0. Total expenses 433,525. Pharmacy: Program service expenses 598,735. Management and general expenses 0. Fundraising expenses 0. Total expenses 598,735. Physicians: Program service expenses 1,960,030. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,960,030. Lab: Program service expenses 423,244. Management and general expenses 0. Fundraising expenses 0. Total expenses 423,244. Emergency room: Program service expenses 146,391. Management and general expenses 0. Fundraising expenses 0. Total expenses 146,391. Physical therapy: Program service expenses 1,042,131. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,042,131. Administrative: Program service expenses 674,920. Management and general expenses 208,483. Fundraising expenses 0. Total expenses 883,403. All other: Program service expenses 298,664. Management and general expenses 92,258. Fundraising expenses 0. Total expenses 390,922.