2013-05-13T15:06:46-05:00 2012-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2011-07-01 810384618 BIG HORN HOSPITAL ASSOCIATION BIGH 4066652310 17 NORTH MILES AVENUE HARDIN MT 59034 GEORGE MINDER 4066652310 2013-05-10 1 ROBERT E SCHILE P00369682 6123764500 2011 2016-02-25 16:41:14Z TERRY BULLIS 17 NORTH MILES AVENUE HARDIN MT 59034 13203160 0 X WWW.BIGHORNHOSPITAL.ORG X 1980 MT TO PROVIDE QUALITY MEDICAL AND HEALTH SERVICES IN BIG HORN COUNTY AND SURROUNDING AREAS. 7 5 246 15 0 0 968104 299468 11815681 12684211 46771 61288 8411 8367 12838967 13053334 32333 50120 0 0 6756927 7596041 0 0 4148 4862707 5249647 11651967 12895808 1187000 157526 11962446 11008998 3586940 2471445 8375506 8537553 X BIG HORN HOSPITAL ASSOCIATION, ALONG WITH ITS AFFILIATED STAFF, WILL WORK TOGETHER TO PROVIDE QUALITY MEDICAL AND HEALTH SERVICES IN BIG HORN COUNTY AND SURROUNDING AREAS. 0 0 11529014 49120 13053334 BIG HORN HOSPITAL ASSOCIATION IS COMPRISED OF BIG HORN HOSPITAL AND HERITAGE ACRES. BIG HORN HOSPITAL IS A 25-BED ACUTE CARE HOSPITAL. HERITAGE ACRES IS A 36-BED NURSING CARE FACILITY AND A 10-UNIT ASSISTED LIVING AND 10-UNIT INDEPENDENT LIVING. DURING THE YEAR ENDED JUNE 30, 2012, BIG HORN HOSPITAL PROVIDED 725 DAYS OF PATIENT SERVICES, 8,040 OUTPATIENT VISITS (INCLUDING 4,280 ER VISITS) AND 4,576 DAYS OF RESIDENT SERVICES; HERITAGE ACRES PROVIDED 12,693 DAYS OF LONG TERM CARE RESIDENT SERVICES AND 3,266 DAYS OF ASSISTED LIVING RESIDENT SERVICES. BIG HORN HOSPITAL ASSOCIATION PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS AT OR BELOW COST AND TO INDIVIDUALS WHO ARE UNABLE TO PAY. THE UNREIMBURSED VALUE OF PROVIDED CARE TO THESE PATIENTS WAS $301,458 FOR THE YEAR ENDED JUNE 30, 2012. 11529014 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 28 0 246 1 0 0 0 0 0 0 0 0 0 0 X 7 5 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 0 1 1 0 0 X ROXIE CAIN CONTROLLER 4066659222 17 N MILES AVENUE HARDIN MT 59034 X TERRY BULLIS 0.40 X X 0 0 0 C WILLIAM FISHER 0.40 X X 0 0 0 JAMES SEYKORA 0.40 X X 0 0 0 SUE MURPHY 0.40 X X 0 0 0 GARY OSTAHOWSKI MD 0.40 X 0 0 0 CHAD FENNER 0.40 X 0 0 0 ROCKY EGGART 0.40 X 0 0 0 GARY ROBERTSON 40.00 X 121794 0 13995 GEORGE MINDER 40.00 X 0 0 0 ROXIE CAIN 40.00 X 79456 0 16643 201250 0 30638 9 0 0 0 DIANE FISCHER - CRNA PC 4395 HIGHWAY 87 N BILLINGS MT 59105 CRNA 135000 1 68560 191563 39345 299468 PATIENT REVENUE 621110 12612354 12612354 OTHER PATIENT REVENUE 900099 38056 38056 CAFETERIA 900099 33801 33801 12684211 43652 43652 157693 149326 8367 8367 8367 17136 1000 0 500 17136 500 17636 17636 13053334 12612354 0 141512 49120 49120 1000 1000 254388 22120 228120 4148 6046932 5642480 404452 91001 79512 11489 751598 654858 96740 452122 413250 38872 2701 2701 71700 71700 1137167 1051709 85458 23781 2412 21369 586710 530008 56702 40845 8476 32369 221230 221230 94578 83019 11559 63648 63648 970390 964944 5446 144155 144155 BAD DEBT 734083 734083 FOOD 238965 238965 MEDICAL SUPPLIES 231285 231285 REPAIRS & MAINTENANCE 191850 191455 395 496559 409088 87471 12895808 11529014 1362646 4148 674348 293621 1997351 1481838 1689210 2118458 122945 106859 142225 193932 73306 79797 17130322 10427139 7131861 6703183 131200 31310 11962446 11008998 1530447 431665 120000 104000 655000 575000 32439 24149 1249054 1336631 3586940 2471445 X 8197768 8359461 177738 178092 8375506 8537553 11962446 11008998 X 157526 4521 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 984 984 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: A PORTION OF THE DUES PAID TO THE MONTANA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION ARE USED FOR LOBBYING PURPOSES. 0 1 418456 418456 12486770 8099665 4387105 4173629 2327474 1846155 51467 51467 6703183 PART IV, LINE 2B: THE HOSPITAL ACTS AS A CUSTODIAN FOR THE FUNDS OF THE NURSING HOME RESIDENTS. THOSE FUNDS APPEAR AS RESTRICTED CASH AND ACCOUNTS PAYABLE IN THE BALANCE SHEET. 1 1 X 1 X 1 X 1 1 1 0 0 376783 376783 0.02920 1671496 2028024 -356528 0.00000 2048279 2028024 20255 0.02920 2048279 2028024 20255 0.02920 1 734083 3920739 3850579 70160 X 1 0 1 1 BIG HORN HOSPITAL ASSOCIATION

17 N MILES HARDIN MT 59034

X X X BIG HORN HOSPITAL ASSOCIATION 1 1 1 150.000000000000 1 300.000000000000 1 X X 1 1 X X X 1 0 1 X 0 0 1 HERITAGE ACRES

200 NORTH MITCHELL HARDIN MT 59034

EXTENDED CARE FACILITY (SNF, ASSISTED LIVING, INDEPENDENT LIVING) PART I, LINE 3C: THE "TEST" FOR COMMUNITY CARE IS IN THE FORM OF INCOME, WHICH IS VERIFIED WITH THE TAX RETURNS. IF A PERSON MEETS THE 150% OF FEDERAL POVERTY GUIDELINES THEIR ENTIRE BILL IS WRITTEN OFF. THE ORGANIZATION THEN PROVIDES A SLIDING FEE SCALE FOR DISCOUNTED CARE UP TO 300% OF THE FEDERAL POVERTY GUILDLINES. THE ORGANIZATION PROVIDES CUSTOMERS WITH AN APPLICATION UPON REQUEST, IF THE CUSTOMER IS STRICTLY PRIVATE PAY OR IF WE HAVE KNOWLEDGE OF A FINANCIAL HARDSHIP. THE ORGANIZATION KEEPS A LOG OF COMMUNITY CARE APPLICATIONS GIVEN TO CUSTOMERS AS WELL AS FOR COMMUNITY CARE AWARDED AND DENIED. PART I, LINE 7: A COST-TO-CHARGE RATIO DERIVED USING WORKSHEET 2 FROM THE IRS WAS USED TO CALCULATE THE AMOUNTS IN PART I, LINE 7. PART I, L7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE EQUAL TO $734,083 INCLUDED IN FORM 990, PART IX, LINE 25 WAS EXCLUDED IN CALCULATING THE PERCENT OF TOTAL EXPENSE IN SCHEDULE H, PART I, LINE 7, COLUMN F. PART III, LINE 4: PART III, LINE 4: THE FOLLOWING IS FROM THE "PATIENT AND RESIDENT ACCOUNTS RECEIVABLE" PARAGRAPH IN NOTE 1 TO THE HOSPITAL'S FINANCIAL STATEMENTS:"THE HOSPITAL REPORTS PATIENT AND RESIDENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYORS, PATIENTS, RESIDENTS AND OTHERS. THE HOSPITAL PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION AND EXISTING ECONOMIC CONDITIONS. AS A SERVICE TO THE PATIENT AND RESIDENT, THE HOSPITAL BILLS THIRD-PARTY PAYORS DIRECTLY AND BILLS THE PATIENTS AND RESIDENT WHEN THE PATIENT AND RESIDENT'S LIABILITY IS DETERMINED. PATIENT AND RESIDENT ACCOUNTS RECEIVABLE ARE ORDINARILY DUE IN FULL WHEN BILLED. DELINQUENT RECEIVABLES ARE WRITTEN OFF BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE PATIENT AND RESIDENT OR THIRD-PARTY PAYOR."THE AMOUNT OF BAD DEBT EXPENSE REPORTS IN PART III, LINE 2 IS CALCULATED AS FOLLOWS: PAYMENT ARRANGEMENT INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE, REIMBURSED COSTS, DISCOUNTED CHARGES AND PER DIEM PAYMENTS. NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PART PAYORS, AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYORS. PART III, LINE 8: THERE IS NO MEDICARE SHORTFALL. BIG HORN HOSPITAL ASSOCIATION IS A CRITICAL ACCESS HOSPITAL WHICH IS REIMBURSED BY MEDICARE AT 101% OF COST. BIG HORN HOSPITAL ASSOCIATION PART V, SECTION B, LINE 9: BHHA UTILIZES A SLIDING FEE SCALE TO DETERMINE THE AMOUNT OF COMMUNITY CARE ASSISTANCE AVAILIABLE TO A SPECIFIC INDIVIDUAL. IF AN INDIVIDUAL (OR FAMILY) IS AT 150% OF THE FEDERAL POVERTY LEVEL OR BELOW, THEY ARE ABLE TO RECEIVE A 100% WRITE OFF ON THEIR SERVICES. THE SCALE GOES UP TO 300% OF THE FEDERAL POVERTY LEVEL AND THAT INDIVIDUAL OR FAMILY WOULD RECEIVE A 20% DISCOUNT ON THEIR SERVICES. BIG HORN HOSPITAL ASSOCIATION PART V, SECTION B, LINE 11H: PATIENTS WHO ARE ELIGIBLE FOR FINANCIAL ASSISTANCE ARE CHARGED THE SAME AMOUNT AS ANY OTHER PATIENT. THE FINANCIAL ASSISTANCE POLICY USES INCOME LEVEL TO DETERMINE A WRITE OFF AMOUNT. BIG HORN HOSPITAL ASSOCIATION PART V, SECTION B, LINE 19D: ROCKY MOUNTAIN HEALTH NETWORK NEGOTIATES COMMERCIAL PAYER CONTRACTS ON BEHALF OF BIG HORN HOSPITAL ASSOCIATION. ROCKY MOUNTAIN HEALTH NETWORK NEGOTIATES A 5% DISCOUNT FOR MOST OF OUR COMMERCIAL PAYERS, SO THAT IS OUR ESTIMATE OF AMOUNTS GENERALLY BILLED. WHEN AN INDIVIDUAL QUALIFIES FOR FINANCIAL ASSISTANCE, WE PROVIDE A 5% ADJUSTMENT THEN PROVIDE AN ADDITIONAL FINANCIAL ASSISTANCE DISCOUNT TO ENSURE THAT NO FAP-ELIGIBLE INDIVIDUAL EVER PAYS MORE THAN AMOUNTS GENERALLY BILLED. PART VI, LINE 2: THE HOSPITAL HAS DONE A MAIL SURVEY TO HELP ASSESS THE NEEDS OF THE COMMUNITY. BHHA ALSO USES COMMUNICATION WITH THE PHYSICIAN PRACTICE AS TO WHAT WOULD BE USEFUL AND NEEDED BY THEIR PAITIENT POPULATION. PART VI, LINE 3: THE FACILITY KEEPS FORMS ON HAND THAT ARE AVAILABLE (ON IN PLAIN SITE) FOR DIFFERENT GOV'T PROGRAMS SUCH AS HEALTH MT KIDS. THE PATIENT ACCOUNTS REPRESENTATIVE WILL INFORM ANY PRIVATE PAY PATIENT OF OUR COMMUNITY CARE AND WILL ALSO RELAY THIS INFORMATION TO CUSTOMERS WHEN DISCUSSING PAYMENT OPTIONS FOR OUTSTANDING BILLS. PART VI, LINE 4: BHHA SERVERS A HIGH POVERTY LEVEL. THEY ARE ON THE EDGE OF THE CROW INDIAN RESERVATION AND HAVE A LOT OF CUSTOMERS WHO UTILIZE INDIAN HEALTH SERVICES AS A PAYOR SOURCE FOR HEALTH CARE. THEIR POPULATION HAS A LARGE POPULATION OF MEDICARE AND MEDICAID CUSTOMERS. AS THEY SERVE A SMALL TOWN IN MONTANA, THE POPULATION CONSISTS OF A LOT OF CHILDREN AS WELL AS ELDERLY, BOTH OF WHICH UTILIZE OUR HEALTHCARE SYSTEM. PART VI, LINE 5: BHHA DOES HAVE A COMMUNITY BOARD TO HELP NOT ONLY "RUN" THE FACILITY WITH POLICIES AND PROCEDURES, BUT TO GIVE INPUT TO THE MANAGEMENT TEAM ABOUT THE NEEDS THEY SEE FOR THE COMMUNITY IN WHICH THEY LIVE. BHHA IS DEVELOPING MORE EDUCATIONAL PROGRAMS FOR ITEMS SUCH AS WOMEN'S HEALTH, DIABETES MANAGMENT AND SMOKING CESASTION.BHHA USES THE LOCAL PAPERS AS AN OUTLET FOR GIVING THE PUBLIC INFORMATION ON DIFFERENT TYPE OF HEALTH CONCERNS, SUCH AS DIABETES, WEIGHT LOSS ETC. THEIR PUBLIC HEALTH EDUCATOR IS DEVELOPING A HEALTH COUNCIL TO HELP EDUCATE AND SHARE IDEAS WITH OTHER HEALTH PROVIDERS IN THE COMMUNITY AS TO THE TYPE OF SERVICES NEEDED IN THE AREA AND HOW TO GET THOSE SERVICES TO THE POPULATION. 1 BIG HORN COUNTY HOSPITAL AND HEALTH CARE FOUNDATION 17 NORTH MILES AVENUE HARDIN MT 59034 810504410 501(C)(3) 24560 TO SUPPORT GENERAL OPERATIONS HERITAGE ACRES AUXILIARY LIMITED PO BOX 474 HARDIN MT 59034 810444017 501(C)(3) 12280 TO SUPPORT GENERAL OPERATIONS BIG HORN COUNTY MEMORIAL HOSPITAL AUXILIARY HC 36 BOX 2065 HARDIN MT 59034 810428249 501(C)(3) 12280 TO SUPPORT GENERAL OPERATIONS 3 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE GRANT MADE WAS AN EQUITY TRANSFER TO A RELATED ORGANIZATION. THESE FUNDS ARE TRACKED THROUGH THE ORGANIZATION'S INTERNAL FINANCIAL REPORTING PROCESS. VERA OSTAHOWSKI EMPLOYEE'S SPOUSE IS A BOARD MEMBER 36695 EMPLOYED AT BIG HORN HOSPITAL ASSOCIATION 0 SUSAN SEYKORA EMPLOYEE'S SPOUSE IS A BOARD MEMBER 56805 EMPLOYED AT BIG HORN HOSPITAL ASSOCIATION. 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE SHALL HAVE ALL THE POWERS OF THE BOARD OF DIRECTORS WHEN THE BOARD IS NOT IN SESSION AND SHALL GENERALLY PERFORM SUCH DUTIES AND EXERCISE SUCH POWERS AS MAY BE PERFORMED AND EXERCISED BY THE BOARD OF DIRECTORS FROM TIME TO TIME. THE FACT THAT THE EXECUTIVE COMMITTEE HAS ACTED SHALL BE CONCLUSIVE EVIDENCE THAT THE BOARD OF DIRECTORS WAS NOT IN SESSION AT THAT TIME. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED IN DETAIL BY THE CONTROLLER AND CEO, A COPY IS NOT PRESENTED TO THE BOARD OF DIRECTORS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C REGULAR COMPLIANCE MEETINGS DISCUSS ANY ACTUAL CONFLICTS OR POTENTIAL CONFLICTS. THERE IS ALSO A HOTLINE NUMBER TO CALL FOR COMPLIANCE OR HIPAA ISSUES THAT IS OPERATED BY MONTANA HOSPITAL ASSOCIATION, NOT BIG HORN HOSPITAL ASSOCIATION. BOARD MEMBERS SIGN YEARLY CONFLICT OF INTEREST STATEMENTS AND IF A CONFLICT OCCURS ON A SPECIFIC ITEM, THEY ABSTAIN FROM THE VOTE ON THAT ITEM. THERE ARE TWO BOARD MEMBERS THAT HAVE SPOUSES EMPLOYED BY BIG HORN HOSPITAL ASSOCIATION. THEY ABSTAIN FROM ANY VOTES THAT WOULD AFFECT WAGES AND BENEFITS FOR EMPLOYEES. FORM 990, PART VI, SECTION B, LINE 15A BIG HORN HOSPITAL ASSOCIATION UTILIZES THE MONTANA STATE SALARY SURVEY TO MAKE SURE EMPLOYEE WAGES ARE COMPARABLE TO SIMILAR JOBS IN SIMILAR AREAS. EXPERIENCE IS ALSO A FACTOR IN THE WAGE. THIS PROCESS WAS LAST DONE IN 2012. THE BOARD REVIEWS AND APPROVES THE CEO'S COMPENSATION AND WAS LAST DONE IN 2012. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE MADE AVAILABE TO THE PUBLIC UPON REQUEST TO THE BUSINESS OFFICE. ALLOCATION OF HOURS FORM 990, PART VII, SECTION A TERRY BULLIS, JAMES SEYKORA, AND WILLIAM FISHER, BOARD MEMBERS OF BIG HORN HOSPITAL ASSOCIATION, ALSO SERVE ON THE BOARD OF DIRECTORS FOR THE BIG HORN COUNTY HOSPITAL AND HEALTH CARE FOUNDATION, A RELATED ORGANIZATION. ROXIE CAIN, CONTROLLER OF BIG HORN HOSPITAL ASSOCIATION, ALSO SERVES THE BIG HORN COUNTY HOSPITAL AND HEALTH CARE FOUNDATION, A RELATED ORGANIZATION. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -58,898. RESTRICTED GRANTS INCLUDED ON FOUNDATION BOOKS 20,000. INTERCOMPANY CONTRIBUTIONS 43,424. ROUNDING -5. TOTAL TO FORM 990, PART XI, LINE 5: 4,521. BIG HORN COUNTY MEMORIAL HOSPITAL AND HEALTHCARE FOUNDATION 17 N MILES AVENUE HARDIN MT 59034 810504410 HOSPITAL FUNDRAISING MT 501(C)(3) 11 TYPE 1 N/A 0 BIG HORN COUNTY MEMORIAL HOSPITAL AUXILIARY HC 36 BOX 2065 HARDIN MT 59034 810428249 FUNDS TO BENEFIT BIG HORN COUNTY MEMORIAL HOSPITAL MT 501(C)(3) 11 TYPE 2 N/A 0 HERITAGE ACRES AUXILIARY LIMITED PO BOX 474 HARDIN MT 59034 810444017 FUNDS TO BENEFIT HERITAGE ACRES NURSING HOME MT 501(C)(3) 11 TYPE 2 N/A 0 0 1 1 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0