2013-09-09T13:38:52-07:00 2012-12-31 990 2012-01-01 311156960 FAIRMONT GENERAL HOSPITAL INC FAIR 3043677100 1325 LOCUST AVENUE FAIRMONT WV 26554 Daniel Honerbrink 3043677100 2013-09-09 2012 2016-02-24 21:20:13Z DANIEL C HONERBRINK 1325 LOCUST AVENUE FAIRMONT WV 26554 89604301 0 X WWW.FGHI.COM X 1985 WV THE ORGANIZATION OPERATES A HOSPITAL THAT PROVIDES PATIENT CARE FOR THE COMMUNITY. 9 9 962 0 0 0 27637 15699 88876376 81503053 337619 95005 2389816 6012875 91631448 87626632 0 0 0 0 41178362 40771904 0 0 0 50278688 47297665 91457050 88069569 174398 -442937 54563136 47106372 39856835 36978037 14706301 10128335 THE ORGANIZATION IS A HOSPITAL WHICH PROVIDES INPATIENT AND OUTPATIENT CARE TO THE COMMUNITY, AS WELL AS HEALTH DIAGNOSTIC, INTERVENTION AND TREATMENT. 0 0 47174381 0 53861877 PATIENT CARE: THE HOSPITAL PROVIDES INPATIENT AND OUTPATIENT HOSPITAL CARE TO THE COMMUNITY, INCLUDING GENERAL MEDICAL, INTENSIVE/CARDIAC CARE, WOMEN'S AND CHILDREN'S HEALTHCARE SERVICES AND INPATIENT DRUG AND ALCOHOL REHAB 3671322 0 10125 ANCILLARY SERVICES: THE HOSPITAL HAS ANCILLARY SERVICES WHICH PROVIDE THE NECESSARY DIRECT SUPPORT TO THE PATIENT CARE DEPARTMENTS. SOME OF THE ANCILLARY SERVICES INCLUDE HOUSEKEEPING, NUTRITION, AND STERILE SUPPLY. 3828212 0 13808543 HEALTH DIAGNOSTIC, INTERVENTION, AND TREATMENT: THE HOSPITAL ALSO OFFERS OUTPATIENT DIAGNOSTIC IMAGING SERVICES. SOME OF THE OF RADIOLOGY DEPARTMENT SERVICES INCLUDE RADIOLOGY DIAGNOSTIC, EKG, ULTRASOUND, MRI, NUCLEAR MEDICINE, CT SCAN, AND PET SCAN. 3846781 0 13822509 LABORATORY SERVICES: THE HOSPITAL ALSO HAS SEVERAL LABORATORY DEPARTMENTS INCLUDING PATHOLOGY, HEMATOLOGY, MICROBIOLOGY, CHEMISTRY, LAB DIAGNOSTIC AND BLOODBANK. 1758385 0 1324635 WELLNESS CENTER: THE HOSPITAL OPERATES A WELLNESS CENTER FOR THE BENEFIT OF THE COMMUNITY TO PROMOTE OVERALL PHYSICAL WELL-BEING. 5605166 0 15147144 60279081 1 0 0 1 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0 0 1 52 0 962 1 0 0 0 0 0 0 X 9 9 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 X DANIEL HONERBRINK CFO 3043677100 1325 LOCUST AVENUE FAIRMONT WV 26554 MIKE MARTIN 0 0 X 0 0 0 TONI NESSELROTTE 0 0 X 0 0 0 PATRICK BONASSO MD 0 0 X 0 0 0 RANDY ELLIOTT 0 0 X 0 0 0 JOEDY DARISTOTLE MD 0 0 X 0 0 0 REV WESLEY DOBBS 0 0 X 0 0 0 DAVID FOX 0 0 X 0 0 0 JOHN PANZA 0 0 X 0 0 0 ROBIN SMITH DC 0 0 X 0 0 0 ROBERT MARQUARDT 40 0 X 271603 0 29220 DANIEL HONERBRINK 40 0 X 183061 0 1767 JIM HARRIS 40 0 X 118643 0 7537 MARGARET COSTER 40 0 X 133598 0 14706 TERESA BONASSO 40 0 X 101910 0 28751 808815 0 81981 5 0 1 0 THEREX INC DEPT AT 952740 ATLANTA GA 311922740 THERAPY SERVICES 1320960 SODEXO PO BOX 536922 ATLANTA GA 303536922 DIETARY MANAGEMENT 1750707 DIAMOND HEALTHCARE CORP PO BOX 85050 RICHMOND VA 23285 BEHAVIORAL MEDICINE SERVICES 1617665 PSI PHARMACY PO BOX 71-0716 COLUMBUS OH 43271 PHARMACY SERVICES 1451488 INSIGHT HEALTH CORPORATION PO BOX 847689 DALLAS TX 75284 RADIOLOGY SERVICES 878010 23 0 0 0 0 0 15699 0 15699 81503053 81503053 0 0 81503053 63036 0 0 63036 0 0 0 0 0 0 0 0 213966 0 0 0 213966 0 213966 0 0 213966 1432053 0 1400084 0 31969 0 31969 0 0 31969 0 0 0 0 0 0 0 0 0 0 0 0 307919 577585 -269666 -269666 0 0 FITNESS CENTER REVENUE 624100 1324635 1324635 0 0 REBATES AND REFUNDS 624100 104813 104813 0 0 UPL/ACUTE CARE REVENUE 624100 4570763 4570763 0 0 68364 68364 0 0 6068575 87626632 87301962 0 308971 0 0 0 0 0 0 0 0 808815 0 808815 0 0 0 0 0 26611020 18628144 7982876 0 1182737 803513 379224 0 10165438 6906068 3259370 0 2003894 1361380 642514 0 548826 468255 80571 0 643397 0 643397 0 53438 0 53438 0 0 0 0 0 0 0 0 0 0 0 9834829 6581213 3253616 0 434416 16792 417624 0 528856 114743 414113 0 0 0 0 0 0 0 0 0 2347961 938470 1409491 0 115155 88320 26835 0 0 0 0 0 0 0 0 0 1254338 852197 402141 0 0 0 0 0 3487980 1998884 1489096 0 1057743 0 1057743 0 BAD DEBT EXPENSE 10375509 10375509 0 0 REPAIRS AND MAINTENANCE 1716133 865779 850354 0 TAXES AND ASSESSMENTS 2748146 2196 2745950 0 SUPPLIES AND MATERIALS 10474536 9066658 1407878 0 1676402 1210960 465442 0 88069569 60279081 27790488 0 2923367 323622 11308707 8592300 205208 1360887 1797893 1326567 1029642 852090 95443476 67879563 29944474 27563913 6429722 6123925 924123 963068 54563136 47106372 14520835 13361032 16068946 15398545 3435648 2354112 5831406 5864348 39856835 36978037 X 14706301 10128335 0 0 0 0 14706301 10128335 54563136 47106372 X -442937 389830 0 0 0 -4524859 X 0 1 X 1 0 X 0 0 0 0 0 1 8322 0 0 0 8322 0 SchC_P2B_S00_L01 Schedule C, Part II-B, Line 1 THE HOSPITAL PAYS MEMBERSHIP DUES TO ORGANIZATIONS THAT HAVE VARIOUS LOBBYING EFFORTS. A PERCENTAGE OF THE TOTAL DUES IS ATTRIBUTED TO POLITICAL ACTIVITIES. 1169709 1442805 2612514 0 36787609 19516742 17270867 0 3392545 1987865 1404680 0 52227838 46374956 5852882 0 422970 0 422970 27563913 0 THIRD PARTY SETTLEMENTS 4152302 RELATED PARTY PAYABLE 50809 PROFESSIONAL & GENERAL INS. LIABILITY 1661237 5864348 88594075 389841 0 0 0 389841 88204234 0 -577602 -577602 87626632 88647178 0 0 0 577609 577609 88069569 0 0 0 88069569 SchD_P11_S00_L04b Schedule D, Part XI, Line 4b COST OF GOODS SOLD - FOOD: -577,585 ROUNDING: -17 SchD_P12_S00_L02d Schedule D, Part XII, Line 2d COST OF GOODS SOLD - FOOD: 577,585 ROUNDING: 24 1 1 1 X 1 X 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 10375509 0 24525562 25573785 -1048223 X 1 0 1 1 FAIRMONT GENERAL HOSPITAL INC

1325 LOCUST AVENUE FAIRMONT WV 26554

X X X FAIRMONT GENERAL HOSPITAL INC 1 0 1 1 150 1 300 1 X X X X X X 1 1 X X X 1 X X 1 X X X X 1 X 0 1 SchH_P01_S00_L07 Schedule H, Part I, Line 7 NO AMOUNTS REPORTED IN TABLE 7. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 PATIENT ACCOUNTS RECEIVABLE ARE CARRIED AT THE ORIGINAL CHARGE LESS AN ESTIMATE MADE FOR DOUBTFUL OR UNCOLLECTIBLE ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. 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 ACCOUTNS TO DETERMINE COLLECTION POTENTIAL. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHCIH 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 ONT HE BASIS OF ITS 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 DOUBTFUL ACCOUNTS. RECOVERIES OF ACCOUNTS PREVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION TO THE PROVISION FOR BAD DEBT EXPENSE WHEN RECEIVED. INTEREST IS NOT CHARGE ON PATIENT ACCOUNTS RECEIVABLE. THE HOSPITALS ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR SELF-PAY REMAINDED AT 86 PERCENT OF SELF-PAY ACCOUNTS RECEIVABLE AT DECEMBER 31, 2012 AND 2011. THE HOSPITAL DOES NOT MAINTAIN A MATERIAL ALLOWANCE FOR DOUBTFUL ACCOUNTS FROM THIRD-PARTY PAYORS, NOR DID IT HAVE SIGNIFICANT WRITE OFFS FROM THIRD-PARTY PAYORS. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 THE HOSPITAL PROVIDES CARE TO THE COMMUNITY AT A COST IN EXCESS OF THE PAYMENT RECEIVED FOR MEDICARE PATIENTS. THIS ABSORPTION OF COSTS BENEFITS THE COMMUNITY THE ORGANIZATION SERVES. LINE 6 WAS DETERMINED USING THE COST TO CHARGE RATIO OF 1.042740 FROM THE 2012 MEDICARE COST REPORT FROM WORKSHEET D-1. THE TITLE XVIII PPS HOSPITAL GENERAL INPATIENT ROUTINE SERVICE COST TO CHARGE RATIO WAS MULTIPLIED BY THE MEDICARE RECEIPTS IN LINE 5. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b THE ORGANIZATION'S DEBT COLLECTION POLICY IS TITLED THE CREDIT AND COLLECTION POLICY. IT DISCUSSES NON-DISCRIMINATION OF SERVICE, PAYMENT RESPONSIBILITIES, INSURED PATIENTS, PRE-ADMISSION PROGRAM, PRE-ADMISSION DEPOSITS, THIRD PARTY LITIGATION, PAYMENT ARRANGEMENTS, PAYMENT AGREEMENTS, AND REFERRED FOR OUTSIDE COLLECTION AND LEGAL ACTION. THERE IS NO DISCUSSION OF CHARITY CARE IN THIS POLICY. HOWEVER, THE ORGANIZATION DOES HAVE A SEPARATE CHARITY CARE POLICY. SchH_P05_S0B_L22 Schedule H, Part V, Section B, Line 22 PATIENT CHARGES ARE CONSISTENT BY SERVICE REGARDLESS OF PAYER (MEDICARE, COMMERCIAL, SELF PAY, ETC.). CHARGES MAY BE DISCOUNTED FOR SELF PAY PATIENTS BASED ON THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 THE ORGANIZATION WORKS WITH OTHER VARIOUS ORGANIZATIONS IN THE COMMUNITY TO PROVIDE MULTI-PHASIC AND LAB TESTING FOR THE PUBLIC. THE ORGANIZATION ALSO UTILIZES SATELLITE LOCATIONS AND ADJUSTS ITS HOURS OF SERVICE TO APPROPRIATELY SERVICE THE COMMUNITY'S NEEDS. THE ORGANIZATION ALSO CONDUCTS HEALTH FAIRS AT VARIOUS LOCATIONS THROUGHOUT THE COMMUNITY DURING THE YEAR. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 THE ORGANIZATION EMPLOYS A PATIENT ELIGIBILITY ADVOCATE IN ITS PATIENT ACCOUNTING DEPARTMENT. THIS EMPLOYEE WORKS WITH PATIENTS TO ASSIST THEM WITH THEIR ELIGIBILITY AND FILING FOR STATE AND FEDERAL GOVERNMENTAL PROGRAMS. THIS EMPLOYEE ALSO WORKS WITH OTHER INDIVIDUALS WHO ARE ON THE ORGANIZATION'S FINANCIAL COUNSELING STAFF. IF A PATIENT IS DETERMINED NOT ELIGIBLE FOR GOVERNMENT PROGRAMS, THEY ARE TAKEN TO A FINANCIAL COUNSELOR WHO WILL ASSESS HIS OR HER ELIGIBILITY FOR FINANCIAL ASSISTANCE OR CHARITY CARE. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 THE ORGANIZATION SERVES MARION COUNTY AND OTHER SURROUNDING AREAS IN NORTH CENTRAL WEST VIRGINIA. THE AREA SERVED IS A SMALL, RURAL COMMUNITY. X X X X X 0 0 0 0 0 0 0 0 0 ROBERT MARQUARDT 271603 0 0 0 0 0 0 0 29220 0 300823 0 0 0 DANIEL HONERBRINK 183061 0 0 0 0 0 0 0 1767 0 184828 0 0 0 JIM HARRIS 133598 0 0 0 0 0 0 0 7537 0 141135 0 0 0 MARGARET COSTER 133598 0 0 0 0 0 0 0 14706 0 148304 0 0 0 TERESA BONASSO 101910 0 0 0 0 0 0 0 28751 0 130661 0 0 0 A MARION COUNTY COMMISSION 556000346 2007-07-01 13700000 DESIGN, CONSTRUCTION AND EQUIPPING OF HEALTHPLEX FACILITY 0 1 0 B WEST VIRGINIA HOSPITAL FINANCE AUTHORITY 621256910 2008-02-01 4385000 REFUND THE SERIES 1994 BONDS, FUND DEBT SERVICE RESERVE FUND, PAY ISSUANCE COSTS 0 1 0 A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 B 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 A 0 0 0 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 0 0 0 A 0 0 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 0 0 A 0 B 0 J MIKE MARTIN MR MARTIN IS THE CHAIRMAN OF THE BOARD OF DIRECTORS 34304 MR MARTIN IS THE PRESIDENT OF FK EVEREST INC, AN ELECTRICAL CONTRACTING COMPANY THAT PROVIDES SERVICES TO THE ORGANIZATION 0 PATRICK BONASSO MD DR BONASSO IS THE SECRETARY OF THE BOARD OF DIRECTORS 6067 THE ORGANIZATION PROVIDES PHYSICIAN SERVICES TO DR BONASSO'S PRACTICE 0 F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b THE TAX RETURN IS PREPARED BY THE HOSPITAL ACCOUNTING DEPARTMENT. THE RETURN IS REVIEWED BY BOTH THE CONTROLLER AND THE CHIEF FINANCIAL OFFICER. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c ANNUALLY, THE ORGANIZATION WILL RECEIVE A CONFLICT OF INTEREST DISCLOSURE FROM ALL BOARD MEMBERS, HOSPITAL DIRECTORS, MANAGERS, AND OTHER SENIOR MANAGEMENT LEADERSHIP TEAM MEMBERS. THE BOARD WILL REVIEW THESE TO DETERMINE IF ANYONE HAS A POTENTIAL CONFLICT OF INTEREST. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 THE COMPENSATION COMMITTEE OF THE BOARD REVIEW ANNUALLY THE COMPENSATION OF THE CEO. THE CEO WILL REVIEW ANNUALLY THE COMPENSATION OF THE SENIOR MANAGEMENT TEAM. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 THE HOSPITAL'S FORMS 1023 AND ANNUAL 990, AS WELL AS POLICIES/PROCEDURES AND THE AUDITED FINANCIAL STATEMENTS, ARE AVAILABLE FOR PUBLIC INSPECTION UPON REQUEST. ANY INQUIRIES FROM THE PUBLIC ARE TOLD TO ADDRESS THEIR REQUEST IN WRITING TO THE CHIEF FINANCIAL OFFICER, AND THE HOSPITAL WILL PROVIDE COPIES AS REQUESTED. F990_P11_S00_L09 Form 990, Part XI, Line 9 EQUITY TRANSFERS TO RELATED ORGANIZATIONS (FAIRMONT PHYSICIANS NETWORK AND FAIRMONT MANAGEMENT SERVICES ORGANIZATION) FAIRMONT MANAGEMENT SERVICES ORGANIZATION 211 MARION SQUARE FAIRMONT WV 26554 550739131 OFFICE MANAGEMENT SERVICES FOR PHYSICIANS IN MARION COUNTY WV 324371 209 FAIRMONT GENERAL HOSPITAL INC MARION COUNTY PHYSICIANS-HOSPITAL ORGANIZATION INC 1325 LOCUST AVENUE FAIRMONT WV 26554 550737630 NETWORK OF PHYSICIAN AND HOSPITAL SERVICE CONTRACTING WV 0 0 FAIRMONT GENERAL HOSPITAL INC MARION HEALTH ENTERPRISES INC 1325 LOCUST AVENUE FAIRMONT WV 26554 541916408 50% OF JOINT VENTURE OF DURABLE HOME MEDICAL EQUIPMENT COMPANY WV 0 0 50 PERCENT OWNED BY FAIRMONT GENERAL HOSPITAL INC FAIRMONT PHYSICIANS NETWORK 211 MARION SQUARE FAIRMONT WV 26554 550738905 NETWORK OF PHYSICIANS WV 5882260 605362 FAIRMONT GENERAL HOSPITAL INC FAIRMONT GENERAL HOSPITAL VOLUNTEER ASSOCIATION INC 1325 LOCUST AVENUE FAIRMONT WV 26554 550369033 ORGANIZES VOLUNTEER SERVICES FOR THE HOSPITAL WV N/A PROFESSIONAL AND GENERAL LIABILITY SELF-COVERAGE 1325 LOCUST AVENUE FAIRMONT WV 26554 550622861 ADMINISTERS THE SELF-INSURANCE COVERAGE FOR THE HOSPITAL AND ITS EMPLOYEES WV N/A FAIRMONT GENERAL HOSPITAL FOUNDATION INC 1325 LOCUST AVENUE FAIRMONT WV 26554 550666256 FUNDRAISING ORGANIZATION FOR THE HOSPITAL WV N/A 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 FAIRMONT GENERAL HOSPITAL FOUNDATION INC c 6197 FAIRMONT GENERAL HOSPITAL FOUNDATION INC p 107560 MANUAL (MAILED EXTENSIONS) FILED ON MAY 15, 2013 AND AUGUST 15, 2013.