2013-11-14T08:26:22-06:00 2012-12-31 390758449 WIPFLI LLP 3703 OAKWOOD HILLS PARKWAY EAU CLAIRE WI 54701 990 2012-01-01 390806828 MEMORIAL HOSPITAL INC MEMO 7157433101 216 SUNSET PLACE NEILLSVILLE WI 54456 ROBERT BARTH 7157433101 2013-11-08 1 HOLLY POKRANDT CPA P00449155 7158323407 2013-11-08 2012 2016-02-24 21:20:13Z ROBERT BARTH 216 SUNSET PLACE NEILLSVILLE WI 54456 23028923 0 X WWW.MEMORIALMEDCENTER.ORG X 1954 WI MEMORIAL HOSPITAL'S MISSION IS TO PROVIDE THE COMMUNITIES WE SERVE THE BEST EXPERIENCE IN HEALTH CARE, EDUCATION, AND PREVENTION SUPPORTED BY OUR PILLARS OF PEOPLE, SERVICE, QUALITY AND SAFETY, FINANCE, COMMUNITY, AND GROWTH...ONE PATIENT AT A TIME. MEMORIAL HOSPITAL, INC. PROVIDES SERVICES THROUGH ITS 25-BED CRITICAL ACCESS HOSPITAL, HOME HEALTH AGENCY, ASSISTED LIVING, AS WELL AS 3 RURAL HEALTH CLINICS IN NEILLSVILLE, LOYAL, AND GREENWOOD, WISCONSIN. TO FULFILL COMMUNITY NEEDS, MEMORIAL HOSPITAL, INC. FACILITATES EDUCATIONAL SEMINARS AND SUPPORT GROUPS LED BY MEDICAL AND PROFESSIONAL STAFF AT GREATLY REDUCED-RATES; PROVIDES FREE HEALTH SCREENINGS AT GIVEN TIMES THROUGHOUT THE YEAR; STAFF BOOTHS AT COMMUNITY EVENTS; SERVES AS AN EDUCATION SITE FOR STUDENTS IN HIGH SCHOOL, TECHNICAL COLLEGE, AND UNIVERSITIES; AS WELL AS OTHER NEEDS AS DETERMINED. MEMORIAL HOSPITAL, INC. ALSO ADMINISTERS A CHARITY CARE PROGRAM HELPING TO ENSURE AFFORDABLE ACCESS TO HEALTHCARE. 11 9 283 78 462475 -226796 104597 43408 22637768 22110961 59427 139182 458405 474711 23260197 22768262 0 0 0 0 14159170 15256233 0 0 0 7403465 9148673 21562635 24404906 1697562 -1636644 17909273 16159233 3884093 3720483 14025180 12438750 X TO PROVIDE THE COMMUNITIES WE SERVE THE BEST EXPERIENCE IN HEALTH CARE, EDUCATION, AND PREVENTION, SUPPORTED BY OUR PILLARS OF PEOPLE, SERVICE, QUALITY AND SAFETY, FINANCE, COMMUNITY, AND GROWTH...ONE PATIENT AT A TIME. 0 0 13750616 17892900 MEMORIAL HOSPITAL, INC. (THE "HOSPITAL"), A 25-BED RURAL HOSPITAL, IS A NONPROFIT, NONSTOCK WISCONSIN CORPORATION PROVIDING SERVICES TO NEILLSVILLE, WISCONSIN AND THE SURROUNDING COMMUNITIES. HOSPITAL INPATIENT SERVICES IN 2012 INCLUDED 886 ACUTE CARE PATIENT DAYS, 105 OBSERVATION DAYS, AND 709 SWING BED PATIENT DAYS.EMERGENCY ROOM VISITS TOTALED 3,356 AND SURGERIES AND PROCEDURES TOTALED 873 IN 2012.OTHER HOSPITAL SERVICES PROVIDED IN 2012 INCLUDED BUT WERE NOT LIMITED TO ATHLETIC TRAINING, DIETARY, OBSTETRICS, PAIN MANAGEMENT, PHARMACY, PHYSICAL THERAPY, RADIOLOGY, LABORATORY, CARDIAC REHABILITATION, SPEECH THERAPY, RESPIRATORY THERAPY, OCCUPATIONAL THERAPY, SOCIAL SERVICES, AND DIABETIC EDUCATION. 5784748 3645434 MEMORIAL HOSPITAL, INC. ALSO OWNS AND OPERATES CLINICS LOCATED IN NEILLSVILLE, LOYAL, AND GREENWOOD, WISCONSIN. VISITS TO THESE THREE CLINIC SITES FOR 2012 WAS APPROXIMATELY 24,000. 807997 443816 THE ASSISTED LIVING FACILITY IS AN ALTERNATIVE FOR SENIORS WHO CAN NO LONGER LIVE SAFELY IN THEIR OWN HOME, YET DO NOT NEED 24-HOUR MEDICAL SUPERVISION. SUNSET GARDENS IS A HOUSING AND HEALTH CARE ALTERNATIVE, COMBINING INDEPENDENCE WITH PERSONAL CARE, IN A WARM, DIGNIFIED, HOME-LIKE ATMOSPHERE. SUNSET GARDENS HAS 11 PRIVATE ROOMS AND 2 DOUBLE ROOMS, FOR A COUPLE OR SIBLINGS. MEALS, SNACKS, HOUSEKEEPING, LAUNDRY, CABLE TELEVISION, AND MAINTENANCE SERVICES ARE PROVIDED. SOCIAL AND RECREATIONAL PROGRAMS AND A CHAPEL ARE ALSO PROVIDED. HEALTH CARE SERVICES INCLUDE A REGISTERED NURSE ON-SITE OR ON-CALL 24 HOURS PER DAY, MEDICATION MANAGEMENT, AND PERSONAL CARE SERVICES PROVIDED BY CERTIFIED NURSING ASSISTANTS (SUCH AS ASSISTANCE WITH BATHING, DRESSING, AND GROOMING). THE ASSISTED LIVING PROVIDED APPROXIMATELY 4,900 RESIDENT DAYS. 20343361 1 1 0 1 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 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 46 0 1 283 1 1 1 0 0 0 0 0 0 0 0 0 X 11 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 1 1 1 0 X ROGER SNEATH MEMORIAL HOSPITAL INC 7157433101 216 SUNSET PLACE NEILLSVILLE WI 54456 X ALLAN HOESLY 1.00 0.50 X X 450 0 0 DR JAMES STANGA 45.00 X 304208 0 42733 JEANETTE STEINER 1.00 0.50 X 200 0 0 RICK SZYMANSKI 1.00 0.50 X X 475 0 0 ROBERT BARTH 20.00 X X 21450 0 0 WENDY SIGURDSON 1.00 X 150 0 0 TREVOR WUETHRICH 1.00 X 275 0 0 KEVIN GRAPP 1.00 X 0 0 0 TIM RUETH 1.00 X 0 0 0 DOROTHY WELSH 1.00 X 100 0 0 DR KENNETH WEIMER 40.00 X 203972 0 39143 DR TIMOTHY MEYER 40.00 X 440472 0 16171 SCOTT POLENZ 40.00 X 31958 0 3437 KELLY MOEN 50.00 X 112702 0 41355 BOBBE TEIGEN 40.00 X 158688 0 16225 SHARON LOANEY-BERGSHOLM 44.00 X 76390 0 10120 DR GRACE CRUZ-APOLINARIO 40.00 X 614020 0 41063 DR DAVID PAUSTIAN 40.00 X 324226 0 13348 DR CAROLYN HARDESTY 40.00 X 245701 0 33840 DR AMY SCHNEIDER DE CORTEZ 40.00 X 217974 0 34304 DR DAVID CARLSON 33.00 X 449470 0 17778 3202881 0 309517 17 0 1 0 WI ANESTHESIA SERVICE LLC W5844 ROLLING HILLS DRIVE NEILLSVILLE WI 54456 CRNA SERVICES 475374 RURAL WISCONSIN HEALTH CO-OP 880 INDEPENDENCE LANE SAUK CITY WI 53583 PROFESSIONAL SERVICES 345758 CMDI PO BOX 158 MILACA MN 56353 CT SERVICES 302100 LOCUMTENENSCOM PO BOX 405547 ATLANTA GA 30384 PHYSICIAN COVERAGE 208639 EXPERIENCED RESOURCES LLC PO BOX 201005 BLOOMINGTON MN 55420 INTERIM CNO 161099 6 16349 4000 23059 43408 HOSPITAL REVENUE 621990 17892900 17892900 CLINIC REVENUE 621110 3645434 3645434 ASSISTED LIVING REVENUE 623000 443816 443816 128811 128811 22110961 42803 42803 12236 0 12236 12236 12236 56448 300592 51922 208739 4526 91853 96379 96379 DIET,MAINT,HSKG,LNDRY 722230 462475 462475 462475 22768262 21982150 462475 280229 1520674 1133209 387465 10548484 9070736 1477748 316634 272276 44358 2139086 1848134 290952 731355 620472 110883 394338 394338 130196 130196 2266602 2040980 225622 87851 5822 82029 975169 594848 380321 366447 264575 101872 8446 8446 161165 138558 22607 809893 584743 225150 301527 113523 188004 MEDICAL SUPPLIES 1874639 1874639 BAD DEBT 1171695 1171695 REPAIRS & MAINTENANCE 359085 359085 RECRUITMENT AND MOVING 157240 157240 84380 84380 24404906 20343361 4061545 0 5142924 241301 2361608 5313785 2010074 2199278 387350 514544 242491 304300 14968591 8986840 6332955 5981751 1431871 1604274 17909273 16159233 2080208 2390053 4117 7117 935000 640000 116587 23765 748181 659548 3884093 3720483 X 14025180 12438750 14025180 12438750 17909273 16159233 -1636644 50214 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5767 5767 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: MEMORIAL HOSPITAL, INC. PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THESE DUES ARE PRIMARILY FOR ACCESS TO EDUCATIONAL MATERIALS AND STAFF TRAINING AND DEVELOPMENT. THE WHA HAS NOTIFIED MEMORIAL HOSPITAL THAT $1,224 OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. MEMORIAL HOSPITAL IS ALSO A MEMBER OF THE RURAL WISCONSIN HEALTH COOPERATIVE (RWHC). EACH YEAR, MEMORIAL HOSPITAL PAYS MEMBERSHIP FEES TO RWHC. RWHC PROVIDES SUPPORT SERVICES FOR A NUMBER OF ITS MEMBER HOSPITALS THROUGHOUT THE STATE OF WISCONSIN. SOME OF THE MANY SERVICES PROVIDED TO MEMBER HOSPITALS INCLUDE PROVIDING ASSISTANCE TO ORGANIZATIONS IN FINDING GRANT FUNDING FOR NEW PROGRAMS, LEGAL SERVICES, REIMBURSEMENT REVIEW SERVICES, ACCOUNTING ASSISTANCE, CONTRACTING FOR THERAPIST AND EMERGENCY ROOM PHYSICIAN COVERAGE, AND ADMINISTRATIVE CONSULTING SERVICES. AS A PART OF THESE SERVICES, THE RWHC ALSO DOES PROVIDE ANALYSIS ON CURRENT HEALTHCARE ISSUES IN AN EFFORT TO PROMOTE BETTER HEALTHCARE FOR HOSPITALS IN RURAL COMMUNITIES THROUGH WISCONSIN. ONE OF THESE EFFORTS ALSO INCLUDES SOME LOBBYING ON THE PART OF THE MEMBER ORGANIZATIONS. RWHC DETERMINED THAT $4,543 OF THE FEES PAID IN 2012 RELATED TO LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE HEALTHCARE ENVIRONMENT IN THE STATE OF WISCONSIN. 20673 20673 10798118 6335396 4462722 3887579 2429479 1458100 262221 221965 40256 5981751 UNAMORTIZED BOND ISSUE COSTS 11025 INVESTMENT IN CENTRAL MN DIAGNOSTIC, INC. 373927 DEFERRED COMPENSATION PLAN ASSETS 667322 AMOUNTS RECEIVABLE FROM THIRD-PARTY REIUMBURSEMENT PROGRAMS 252000 OTHER RECEIVABLES 300000 1604274 DEFERRED COMPENSATION LIABILITY 659548 659548 X DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE ORGANIZATION DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE LIKELY THAN NOT RECOGNITION THRESHOLD, THE BENEFIT OF THE TAX POSITION IS NOT RECOGNIZED IN THE CONSOLIDATED FINANCIAL STATEMENTS. THE HOSPITAL IS ALSO ENGAGED, TO A LIMITED EXTENT, IN ACTIVITIES THAT THE INTERNAL REVENUE SERVICE CONSIDERS UNRELATED TO THE HOSPITAL'S EXEMPT PURPOSE AND, THEREFORE, TAXABLE. THESE ACTIVITIES, HOWEVER, ANNUALLY RESULT IN NET OPERATING LOSSES FOR INCOME TAX PURPOSES. THE HOSPITAL DOES NOT PRESENTLY ANTICIPATE THAT A TAX BENEFIT FROM THESE NET OPERATING LOSSES WILL BE REALIZED IN THE FUTURE. ACCORDINGLY, ANY POTENTIAL DEFERRED TAX ASSET RESULTING FROM THE AVAILABILITY OF NET OPERATING LOSS CARRYFORWARDS IS OFFSET BY A VALUATION ALLOWANCE OF EQUAL AMOUNT. NO DEFERRED TAX ASSETS AND LIABILITIES HAVE BEEN RECOGNIZED SINCE NO OTHER DIFFERENCES EXIST BETWEEN THE FINANCIAL AND TAX BASIS OF REPORTING THE HOSPITAL'S ASSETS AND LIABILITIES. THE ORGANIZATION'S POLICY IS TO RECOGNIZE INTEREST AND ANY PENALTIES RELATED TO INCOME TAX MATTERS IN INCOME TAX WHEN INCURRED. AS OF AND FOR THE YEARS ENDED DECEMBER 31, 2012 AND 2011, THERE WAS NO INCOME TAX EXPENSE, TAX PENALTIES, OR INTERST RELATED TO TAX PENALTIES RECORDED BY THE ORGANIZATION IN THE CONSOLIDATED FINANCIAL STATEMENTS. IN ADDITION, THE ORGANIZATION RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2012 AND 2011. FEDERAL RETURNS FOR THE YEARS 2009 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. 1 1 1 X 49.000000000000 1 X 1 1 0 1 1 193871 193871 0.00830 959236 639321 319915 0.01380 2835534 2072130 763404 0.03290 3988641 2711451 1277190 0.05500 21589 1725 19864 0.00090 25741 25741 0.00110 6456296 2254840 4201456 0.18080 19377 19377 0.00080 6523003 2256565 4266438 0.18360 10511644 4968016 5543628 0.23860 310 310 0.00000 1310 1310 0.00010 53 53 0.00000 1056 1056 0.00000 5288 5288 0.00020 825 825 0.00000 8842 8842 0.00030 0 695634 278253 4495443 4544034 -48591 X 1 1 1 1 MEMORIAL HOSPITAL INC

216 SUNSET PLACE NEILLSVILLE WI 54456

X X X X MEMORIAL HOSPITAL INC 1 1 1 49.000000000000 1 300.000000000000 1 X X X X X 1 1 X X X 1 0 1 X 0 0 5 MEMORIAL MEDICAL CENTER

216 SUNSET PLACE NEILLSVILLE WI 54456

PROVIDER BASED RURAL HEALTH CLINIC SUNSET GARDENS

216 SUNSET PLACE NEILLSVILLE WI 54456

ASSISTED LIVING FACILITY GREENWOOD FAMILY MEDICAL CENTER

201 SOUTH MAIN GREENWOOD WI 54437

PROVIDER BASED RURAL HEALTH CLINIC LOYAL CLINIC - MEMORIAL MEDICAL CENTER

502 EAST ELM STREET LOYAL WI 54446

PROVIDER BASED RURAL HEALTH CLINIC MEMORIAL MEDICAL CENTER

216 SUNSET PLACE NEILLSVILLE WI 54456

HOME HEALTH AGENCY PART I, LINE 3C: MEMORIAL HOSPITAL GENERALLY USES 49% OF FEDERAL POVERTY GUIDELINES FOR OFFERING FREE CARE AND A SLIDING SCALE GOING UP TO 300% OFFERING REDUCED CHARGES FOR CARE. IT SHOULD ALSO BE NOTED THAT MEMORIAL HOSPITAL, AS A PART OF ITS COMMUNITY CARE POLICY, WILL ALSO CONSIDER AN ADMINISTRATIVE REVIEW OF OTHER OUTSTANDING BALANCES OF AN INDIVIDUAL. WE WILL DETERMINE ON AN INDIVIDUAL BASIS IF ADDITIONAL DISCOUNTS CAN BE PROVIDED TO PATIENTS. A PATIENT MAY HAVE A SIGNIFICANT OR LONG TERM NEED OF MEDICAL BILLS THAT MAY REQUIRE ADDITIONAL COMMUNITY SUPPORT TO HELP A PATIENT THROUGH A DIFFICULT TIME. PART I, LINE 7: THE CALCULATED PERCENT OF TOTAL EXPENSES EXCLUDES BAD DEBT EXPENSE. THE COSTING METHOD USED ON FORM 990 IS BASED ON A COST TO CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES MINUS THE PROVISION FOR BAD DEBTS AND IT IS DIVIDED BY GROSS PATIENT SERVICE REVENUES. THIS COST TO CHARGE RATIO WAS USED TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER THE IRS SUGGESTED COSTING METHODS FOR THE FORM 990. PART I, LINE 7G: THE COST OF SUBSIDIZED HEALTH SERVICES IS BASED ON COST ALLOCATIONS FROM THE MEDICARE COST REPORT. ALLOWABLE COSTS ARE ASSIGNED DIRECTLY TO DEPARTMENTS THROUGHOUT THE YEAR AND THEN THE COST REPORT USES THE ALLOCATION METHODOLOGY TO ASSIGN ALL OTHER COSTS TO CALCULATE SERVICE LINE COSTS. SUBSIDIZED HEALTH SERVICES INCLUDE THE OPERATION OF THREE FAMILY PRACTICE CLINICS AND EMERGENCY ROOM. IT IS THE GOAL OF MEMORIAL HOSPITAL, INC. TO PROVIDE THESE SERVICES TO THE COMMUNITY REGARDLESS OF A PATIENT'S ABILITY TO PAY. 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 $ 1171695. PART II: COMMUNITY BUILDING ACTIVITIES PROMOTE THE HEALTH OF THE COMMUNITY THAT OUR HOSPITAL SERVES. THROUGH COLLABORATION WITH LOCAL ORGANIZATIONS, WE PROVIDE INFORMATION TO THE COMMUNITY REGARDING VARIOUS ISSUES THAT AFFECT HEALTH SUCH AS BABYSITTING CLASSES, SERVING ON PUBLIC HEALTH BOARDS, WORKING WITH DISASTER PREPAREDNESS, CPR CLASSES, DIABETIC SUPPORT GROUPS, PRESCRIPTION ASSISTANCE, STRESS MANAGEMENT, PREVENTATIVE SERVICES, AND OTHERS. PART III, LINE 4: BAD DEBTS ARE RECORDED IN A CONSISTENT MANNER WITH THE ORGANIZATION'S COLLECTION POLICIES. THE TOTAL IS RECORDED IN GROSS CHARGES AND THEN THE COST TO CHARGE RATIO IS APPLIED TO CALCULATE THE COST OF BAD DEBTS.THERE ARE A NUMBER OF PATIENTS THAT TRULY DO NOT HAVE THE ABILITY TO PAY BUT DO NOT FILL OUT THE PAPERWORK TO RECEIVE CHARITY CARE. THE FACILITY DOES NOT HAVE A PRESUMPTIVE ELIGIBILITY PROGRAM AT THIS TIME TO IDENTIFY THOSE INDIVIDUALS. OUR FACILITY CONTINUES TO PROVIDE HEALTHCARE TO THOSE IN NEED REGARDLESS OF THEIR ABILITY TO PAY. FOR THE BAD DEBTS RECORDED THERE WERE SERVICES PROVIDED TO IMPROVE THE HEALTH OF OUR COMMUNITY. THIS CARE WAS PROVIDED WITH COMMUNITY BENEFIT MOTIVATIONS. THE AUDITED FINANCIAL STATEMENTS DO NOT INCLUDE A SEPARATE FOOTNOTE REGARDING BAD DEBT EXPENSE.PATIENT RECEIVABLES AND CREDIT POLICY FINANCIAL STATEMENT FOOTNOTEPATIENT ACCOUNTS RECEIVABLE PRIMARILY CONSIST OF UNCOLLATERALIZED PATIENT OBLIGATIONS THAT ARE STATED AT THE AMOUNT MANAGEMENT EXPECTS TO COLLECT FROM OUTSTANDING BALANCES. THESE OBLIGATIONS ARE PRIMARILY FROM LOCAL RESIDENTS, MOST OF WHOM ARE INSURED UNDER THIRD-PARTY PAYOR AGREEMENTS. THE HOSPITAL BILLS THIRD-PARTY PAYORS ON THE PATIENTS' BEHALF, OR IF A PATIENT IS UNINSURED, THE PATIENT IS BILLED DIRECTLY. ONCE CLAIMS ARE SETTLED WITH THE PRIMARY PAYOR, ANY SECONDARY INSURANCE IS BILLED, AND PATIENTS ARE BILLED FOR COPAY AND DEDUCTIBLE AMOUNTS THAT ARE THE PATIENTS' RESPONSIBILITY. PAYMENTS ON PATIENT ACCOUNTS RECEIVABLE ARE APPLIED TO THE SPECIFIC CLAIM IDENTIFIED ON THE REMITTANCE ADVICE OR STATEMENT.THE HOSPITAL DOES HAVE A POLICY TO CHARGE INTEREST ON ACCOUNTS NEEDING EXTENDED PAYMENT BEYOND ONE YEAR. THE HOSPITAL WILL SET UP LONG-TERM PAYMENT PLANS FOR THESE TYPES OF ACCOUNTS. THESE PATIENTS SIGN AN AGREEMENT WITH THE HOSPITAL TO REPAY THE BALANCE IN APPROXIMATELY TWO YEARS AND WILL BE ASSESSED INTEREST AT A RATE OF 0.833% PER MONTH OR 10% ANNUAL INTEREST ON THE BALANCES OUTSTANDING.PATIENT ACCOUNTS RECEIVABLE ARE RECORDED IN THE CONSOLIDATED BALANCE SHEETS NET OF CONTRACTUAL ADJUSTMENTS AND ALLOWANCES FOR UNCOLLECTIBLE ACCOUNTS WHICH REFLECT MANAGEMENT'S BEST ESTIMATE OF THE AMOUNTS THAT WILL NOT BE COLLECTED. MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH A REDUCTION TO GROSS MEDICAL SERVICE REVENUE AND A CREDIT TO ACCOUNTS RECEIVABLE. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF PATIENT ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES PAST RESULTS AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAY SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE 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 UNCOLLECTIBLE ACCOUNTS. SPECIFICALLY, FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS AND PATIENTS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES 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 THEIR 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 UNCOLLECTIBLE ACCOUNTS. PART III, LINE 8: MEMORIAL HOSPITAL IS DESIGNATED A CRITICAL ACCESS HOSPITAL AND AS SUCH A PORTION OF ITS REVENUES ARE PAID UNDER A COST REIMBURSEMENT SYSTEM. BASED ON THE INSTRUCTIONS, THE TOTAL MEDICARE REVENUE SHOWN ON THIS FORM 990 INCLUDES ONLY A PORTION OF THE GROSS MEDICARE REVENUE THAT IS ACTUALLY RECEIVED BY THE HOSPITAL FROM THE MEDICARE PROGRAM. THE AMOUNTS LISTED FOR MEDICARE DO NOT INCLUDE PHYSICIAN AND MID-LEVEL PRACTITIONER SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT MEMORIAL HOSPITAL OR ANESTHESIA SERVICES. PHYSICIAN COVERAGE IS REIMBURSED PRIMARILY ON A FEE SCHEDULE REIMBURSEMENT METHODOLOGY AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY AND ANESTHESIA SERVICES PROVIDED TO MEDICARE PATIENTS ARE VITAL TO THE WELL-BEING OF THE COMMUNITY AND AS SUCH THESE COSTS AND SHORTFALLS SHOULD ALSO BE CONSIDERED AS AN ADDITIONAL BENEFIT THAT MEMORIAL HOSPITAL PROVIDES TO THE COMMUNITY AND SURROUNDING AREA OF NEILLSVILLE, WISCONSIN. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON AN OVERALL AVERAGE COST TO CHARGE RATIO AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUES (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE) DIVIDED BY TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT EXPENSE. THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES WHICH ARE REIMBURSED ON A COST METHODOLOGY EXCLUDING THE FEE SCHEDULE ITEMS LIKE PHYSICIAN AND MID-LEVEL PRACTITIONER SERVICES WHICH THE HOSPITAL WOULD SHOW A LARGE LOSS ON THESE SERVICES.WHETHER THERE IS A SHORTFALL OR SURPLUS FROM SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THE RECIPIENTS ARE TYPICALLY ELDERLY AND/OR DISABLED MEMBERS OF THE COMMUNITY AND ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. PART III, LINE 9B: UNINSURED PATIENTS ARE GIVEN THE OPPORTUNITY TO FILL OUT AN APPLICATION FOR CHARITY CARE AT THE TIME OF ADMISSION AND ALL PATIENTS ARE ASKED TO FILL OUT A CHARITY CARE APPLICATION DURING THE COLLECTION PROCESS PRIOR TO SENDING TO ANY ACCOUNTS TO A COLLECTION AGENCY. IF THE PAPERWORK IS NOT RECEIVED, THE ACCOUNT IS HANDLED THROUGH THE NORMAL COLLECTION PROCESS. MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 14G: A LETTER DESCRIBING THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY IS SENT TO PATIENTS FOR EVERY SERVICE PROVIDED WHERE THEY REGISTERED AS PRIVATE PAY. A LETTER IS ALSO SENT TO PATIENTS AGAIN WHEN NO PAYMENT HAS BEEN RECEIVED AFTER TWO STATEMENTS. MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 20D: MAXIMUM AMOUNTS THAT CAN BE CHARGED TO INDIVIDUALS ARE AS FOLLOWS:PATIENTS WHOSE INCOME IS 49% OF LESS OF THE FEDERAL POVERTY GUIDELINES RECEIVE FREE CARE.PATIENTS WHOSE INCOME IS BELOW 200% OF THE FEDERAL POVERTY GUIDELINES RECEIVE THE LOWEST NEGOTIATED COMMERCIAL RATE.PATIENTS WHOSE INCOME IS BELOW 300% OF THE FEDERAL POVERTY GUIDELINES RECEIVE A 10% DISCOUNT FROM GROSS CHARGES. PART VI, LINE 2: DURING 2009 MEMORIAL HOSPITAL, INC ENTERED INTO A FORMAL COMMUNITY NEEDS ASSESSMENT WITH CLARK COUNTY IN ORDER TO SPECIFICALLY ADDRESS PUBLIC HEALTH, WIC, SCHOOLS, ORGANIZATIONS ADVOCATING FOR THE ELDERLY ETC. AND MAINTAIN MEMBERSHIPS IN OTHER COMMUNITY ORGANIZATIONS TO STAY IN TOUCH WITH THE COMMUNITY. ALSO DURING 2009 MEMORIAL HOSPITAL, INC STARTED A COMMUNITY HEALTH COUNCIL THAT MEETS QUARTERLY. THIS COUNCIL IS COMPRISED OF APPROX 30 COMMUNITY MEMBERS REPRESENTING OUR FULL SERVICE AREA. THE PURPOSE OF THIS GROUP IS TO GAIN DIRECT INPUT FROM COMMUNITY MEMBERS ON UNMET HEALTH NEEDS AND POSSIBLE SOLUTIONS TO FILL GAPS. PART VI, LINE 3: ALL PATIENTS WHO REGISTER WITH NO INSURANCE ARE SENT A PRIVATE PAY LETTER NOTIFYING THEM TO CONTACT A FINANCIAL SERVICES REPRESENTATIVE AT MEMORIAL HOSPITAL, INC. IF THEY NEED HELP IN PAYING THEIR BILL. THE LETTER ALSO HIGHLIGHTS THE CHARITY CARE PROGRAM AND GIVES THE WEBSITE WHERE THE APPLICATION CAN BE FOUND. THE FINANCIAL SERVICES REPRESENTATIVE THEN DISCUSSES THE OPTIONS AVAILABLE TO THE PATIENT. PART VI, LINE 4: MEMORIAL HOSPITAL, INC SERVES IN A COUNTY IN WHICH 28% OF THE POPULATION EARNS LESS THAN 200% OF THE FEDERAL POVERTY LEVEL AND 25% OF THE POPULATION ARE UNINSURED. THE COMMUNITY HAS A HIGH POPLULATION OF ELDERLY AND AMISH/MENNONITE. TRANSPORTATION IS HIGHLY UNDER-DEVELOPED AND UNAVAILABLE. THE COUNTY IS DESIGNATED AS A HEALTH PROFESSIONAL SHORTAGE AREA AND MEDICALLY UNDERSERVED AREA. MEMORIAL HOSPITAL, INC SERVES ROUGHLY A 25 MILE RADIUS WITH A POPULATION TOTAL OF 15,000. PART VI, LINE 5: WHILE THERE IS GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFIT HOSPITAL'S COMMUNITY BENEFIT, THIS IS A WORK IN PROGRESS. OUR HOSPITAL PROVIDES CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS. BUT IN ADDITION, WE BELIEVE THAT WE PROVIDE A CRITICALLY IMPORTANT COMMUNITY BENEFIT WHICH IS NOT QUANTIFIED. OUR HOSPITAL, LIKE MOST RURAL HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY. BEYOND INPATIENT HOSPITALIZATIONS, WE PROVIDE LOCAL ACCESS TO MANY HEALTH SERVICES: BIRTHING CENTER, DIAGNOSTICS, EMERGENCY SERVICES & URGENT CARE, HOME CARE, INFUSION SERVICES, LABORATORY SERVICES, OCCUPATIONAL HEALTH, REHABILITATION SERVICES, SPECIALTY MEDICINE, SLEEP CENTER, SPEECH AND AUDIOLOGY, SURGICAL SERVICES, AND WOMENS HEALTH SERVICES. REPORTS FILED WITH STATES PART VI, LINE 7 WI X X X X X 1 1 0 1 0 0 0 0 0 DR JAMES STANGA 165405 0 138650 0 153 0 4500 0 38233 0 346941 0 0 0 DR KENNETH WEIMER 152899 0 50972 0 101 0 4500 0 34643 0 243115 0 0 0 DR TIMOTHY MEYER 181562 0 258757 0 153 0 4500 0 11671 0 456643 0 0 0 KELLY MOEN 103700 0 8921 0 81 0 4500 0 36855 0 154057 0 0 0 BOBBE TEIGEN 130390 0 28005 0 293 0 0 0 16225 0 174913 0 0 0 DR GRACE CRUZ-APOLINARIO 171092 0 442775 0 153 0 4500 0 36563 0 655083 0 0 0 DR DAVID PAUSTIAN 79037 0 182529 0 62660 0 4500 0 8848 0 337574 0 0 0 DR CAROLYN HARDESTY 122659 0 122961 0 81 0 0 0 33840 0 279541 0 0 0 DR AMY SCHNEIDER DE CORTEZ 128701 0 89191 0 82 0 0 0 34304 0 252278 0 0 0 DR DAVID CARLSON 296265 0 152700 0 505 0 0 0 17778 0 467248 0 0 0 PART I, LINES 4A-B MEMORIAL HOSPITAL, INC. OFFERS AN EXECUTIVE 457(F) RETIREMENT PLAN, ESTABLISHED IN 2006, IN WHICH THE EMPLOYER MAY MAKE DISCRETIONARY CREDITS TO THE DEFERRED COMPENSATION ACCOUNT OF THE PARTICIPANTS IN AN AMOUNT DETERMINED EACH PLAN YEAR BY THE EMPLOYER. CURRENT YEAR DISTRIBUTIONS TOTALED $301,698. PART I, LINE 5 IN 2012, THE FOLLOWING PHYSICIANS RECEIVED COMPENSATION THAT WAS PARTLY BASED ON THE GROSS CHARGES RECOGNIZED FOR THEIR PROFESSIONAL SERVICES: DR. JAMES STANGA $53,164; DR. DAVID PAUSTIAN $92,033; DR. TIMOTHY MEYER $98,125; DR. GRACE CRUZ-APOLINARIO $210,769; DR. CARYLYN HARDESTY $71,139; DR. KENNETH WEIMER $794. SUPPLEMENTAL INFORMATION PART III PART I, LINE 4A: INCLUDED ON SCHEDULE J, PART II, COLUMN B (III) IS SEVERANCE PAY OF $53,952 PAID TO ONE PHYSICIAN. FORM 990, PART VI, SECTION B, LINE 11 THE INTERIM CFO DETAIL REVIEWS THE FORM PRIOR TO SUBMISSION. ALSO, BEFORE THE RETURN WAS FILED, A PRELIMINARY COPY WAS MADE AVAILABLE TO THE BOARD OF DIRECTORS FOR REVIEW AND COMMENTS. FORM 990, PART VI, SECTION B, LINE 12C MEMORIAL HOSPITAL RELIES ON THE ANNUAL DISCLOSURE OF KEY INDIVIDUALS TO THE BOARD OF DIRECTORS AND MONITORS PURCHASES AND ABSTENTIONS FROM NECESSARY VOTES THROUGHOUT THE YEAR. ALL MANAGERS AND MEDICAL STAFF ARE REQUIRED TO DISCLOSE AND FOLLOW THE CONFLICT OF INTEREST POLICY. FORM 990, PART VI, SECTION B, LINE 15 A COMMITTEE OF THE BOARD OF DIRECTORS HAS BEEN DESIGNATED TO REVIEW ALL EXECUTIVE PAY CHANGES. MARKET DATA IS PROVIDED TO THE COMMITTEE IN THEIR EVALUATION OF PAY CHANGES. COMPARABILITY DATA WAS USED AND THE RESULTS OF ANY EXECUTIVE PAY CHANGES WERE DOCUMENTED. NO ONE WITH A CONFLICT OF INTEREST WAS INCLUDED IN THE DECISION MAKING OF EXECUTIVE COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 ALL DOCUMENTS ARE AVAILABLE UPON REQUEST. DOCUMENTS ARE ALSO DISCUSSED AT COMMUNITY MEETINGS AND EMPLOYEE FORUMS. EXPLANATION FOR HOURS WORKED: FORM 990, PART VII, LINE 1A SOME OFFICERS AND BOARD MEMBERS ALSO PROVIDED SERVICE TO COUNTRY VIEW, INC., A RELATED ORGANIZATION. THESE HOURS ARE REFLECTED IN LINE 2 OF COLUMN B. FORM 990, PART XII, LINE 2C THE BOARD OF DIRECTORS IS RESPONSIBLE FOR THE SELECTION OF AN INDEPENDENT AUDITOR AND MANAGEMENT OVERSEES THE AUDIT PROCESS. THIS PROCESS DID NOT CHANGE IN 2012. COUNTRY VIEW INC 216 SUNSET PLACE NEILLSVILLE WI 54456 391411586 HUD HOUSING WI 501(C)(3) LINE 9 MEMORIAL HOSPITAL INC 1 THE FOUNDATION OF MEMORIAL HOSPITAL INC 216 SUNSET PLACE NEILLSVILLE WI 54456 383800811 FUNDRAISING WI 501(C)(3) LINE 7 MEMORIAL HOSPITAL INC 1 0 0 1 0 0 0 0 0 0 0 0 1 0 0 1 0 1 0 0