2013-08-15T16:48:46-05:00 2012-09-30 420714325 MCGLADREY LLP 1 S WACKER DRIVE STE 800 CHICAGO IL 60606 990 2011-10-01 361564290 Norwegian American Hospital Inc NORW 7732928200 1044 North Francisco Avenue Chicago IL 606222743 Anthony Evers 7732928200 2013-08-15 1 Wayne Harder P00294296 3126343400 2011 2016-02-24 21:20:13Z Anthony Evers 1044 North Francisco Avenue Chicago IL 606222743 108676274 0 X www.nahospital.org X 1935 IL Norwegian American Hospital provides quality and compassionate health care services by partnering with patients, their families, our employees, physicians, and the communities we serve. 15 13 1121 41 -151133 -151133 7368620 244439 104206058 108355310 47198 37025 -17670 -151133 111604206 108485641 0 0 0 0 51560570 51898800 0 0 0 57667454 56277998 109228024 108176798 2376182 308843 95583955 110887572 65863584 82112613 29720371 28774959 X Norwegian American Hospital is the hospital of choice for our communities and our caregivers. We are the best in class for clinical care, customer service, employee engagement, access to care and stewardship. 0 0 87350149 108090017 Norwegian American Hospital is a premier health care provider where the patient comes first. As an organization of caregivers, Norwegian American inspires to consistently high standards of quality, family-centered health care services and cost effectiveness. Norwegian American Hospital seeks to promote wellness within the family and to be dynamic partners in health with the communities it serves. For the fiscal year ended September 30, 2012, Norwegian American Hospital forgone $5,326,000 worth of charges for healthcare services and supplies provided to members of the communities served under its charity care policy. These members did not have the ability to pay for services received. Norwegian American also provided care to patients who are beneficiaries of Medicare, Medicaid, blue cross and managed care reimbursement programs. Reimbursement amounts for these programs are less than charges and in some cases less than cost. For fiscal year 2012, Norwegian American Hospital served 7,867 patients admitted who received 34,510 days of healthcare services. 87350149 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 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 155 0 1 1121 1 1 1 0 0 0 0 0 0 0 0 0 X 15 13 0 0 0 0 0 0 0 1 1 0 1 1 0 1 1 1 1 1 0 0 0 IL X Anthony Evers CFO 7732928200 1044 North Franscisco Ave Chicago IL 606222743 Marta Cerda 10.00 X X 0 0 0 Billy Ocasio 4.00 X X 0 0 0 Sandra Valenzuela 8.00 X X 0 0 0 Louis Tinajero 8.00 X X 0 0 0 Patrick Driscoll 2.00 X 0 0 0 Ibrahim A Majzoub MD 2.00 X 0 0 0 Duke Miglin 2.00 X 0 0 0 Hector J Rodriguez 2.00 X 0 0 0 Carmen C Hovanec 2.00 X 0 0 0 Enrique Lopez 2.00 X 0 0 0 Wilmi Schmidt 2.00 X 0 0 0 John Monteverde 2.00 X 0 0 0 Rafaela Munoz-Ulrich 2.00 X 0 0 0 Jose R Sanchez 40.00 X X 669394 0 65238 Anthony Evers 40.00 X 187114 0 15256 Matthew J Lambert III 40.00 X 278014 0 22381 Carrie L Smith 40.00 X 243729 0 24662 Murali Vinta 40.00 X 271280 0 22351 Cesar A Carranza 40.00 X 221041 0 17743 Kenneth Moore 40.00 X 178803 0 18721 Qaiser Jamal 40.00 X 178351 0 18247 2227726 0 204599 53 0 1 0 IllinoisIndiana EM-I Medical Services 7032 Collection Center Drive Chicago IL 60693 Emergency Services 1651413 Novak Construction 3423 N Drake Chicago IL 60618 Construction 1027633 Family Guidance Center Inc 310 W Chicago Chicago IL 60610 Medical Detox Services 657996 Krause Construction 3330 Edison Street Blue Island IL 60406 Construction 598649 HLS Laundry Services 45 W Hintz Road Wheeling IL 60090 Linen/Laundry Services 456159 27 244439 244439 Medicare/Medicaid Paym 621110 66737674 66737674 Medicaid Assessment Re 621110 17997156 17997156 Net Patient Services 621110 16684418 16684418 Operating Revenue 621110 3683962 3683962 Medicaid EHR Incentive 621110 2986807 2986807 265293 265293 108355310 35525 35525 39500 190633 -151133 -151133 -151133 1500 0 1500 1500 1500 108485641 108090017 -151133 302318 1137687 864642 273045 42842656 32560419 10282237 265000 201400 63600 4611832 3504992 1106840 3041625 2311635 729990 5003980 3803025 1200955 671692 510486 161206 143253 143253 252560 252560 3868491 3130593 737898 75176 57134 18042 152808 116134 36674 54291 41261 13030 4133699 3286492 847207 19713 14982 4731 181816 138180 43636 1640339 1640339 3965608 3013862 951746 3974196 3020389 953807 Provision for Bad Debt 11421745 11421745 Medical Supplies 8594537 8594537 IL Medicaid Tax Assessm 6433038 6433038 Repairs & Maintenance 2000838 1520637 480201 3690218 2804566 885652 108176798 87350149 20826649 0 7463503 4361786 12090208 15794932 7000000 3500000 11985509 15646620 1141445 1035055 3049608 2200183 120889749 82568565 35587160 38321184 6354479 5010517 10912043 25017295 95583955 110887572 9553977 10153290 4746520 3362809 21825392 21155932 234540 29503155 47440582 65863584 82112613 X 19942936 22237723 9777435 6537236 29720371 28774959 95583955 110887572 X 308843 -1254255 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 205833 0 1 46727 252560 0 Explanation of Lobbying Activities: Part II-B, Line 1: Part of membership dues paid to Illinois Hospital Association and Metropolitan Chicago Healthcare Council are used for lobbying purposes. 4529913 4529913 44815368 29921876 14893492 3112770 3023687 89083 63004554 49623002 13381552 5427144 5427144 38321184 Insurance Recoveries Receivable 14021460 Property Held for Future Use 1189446 Investment in Joint Venture 6525340 Due from Affiliates 53764 Beneficial Interest in Net Assets of Foundation 2454590 Investment in Subsidiary 741239 Other Assets 31456 25017295 Accrued Malpractice Liability 25605979 Conditional Asset Retirement Obligation 2874300 Net Pension Liability 17322612 Sodexho Capital Lease 11116 Due to Third-Party Programs 1561720 Deferred Lease 64855 47440582 Description of Uncertain Tax Positions Under FIN 48: Part X: The Hospital is a tax-exempt organization under Internal Revenue Code Section 501(c)(3) and, accordingly, no income taxes are provided for in the accompanying consolidated financial statements relating to these organizations. The Hospital files Form 990 (Return of Organization Exempt from Income Tax. When this return is filed, it is highly certain that some positions taken would be sustained upon examination by the taxing authorities, while others are subject to uncertainty about the merits of the position taken or the amount of the position that would ultimately be sustained. Examples of tax positions common to health systems include such matters as the following: the tax-exempt status of each entity, the continued tax-exempt status of bonds issued by the obligated group, the nature, characterization and taxability of joint venture income and various positions relative to potential sources of unrelated business taxable income (UBIT). UBIT is reported on Form 990T, as appropriate. The benefit of a tax position is recognized in the consolidated financial statements in the period during which, based on all available evidence, management believes that it is more likely than not that the position will be sustained upon examination, including the resolution of appeals or litigation processes, if any. Tax positions are not offset or aggregated with other positions. Tax positions that meet the "more likely than not" recognition threshold are measured as the largest amount of tax benefit that is more than 50 percent likely to be realized on settlement with the applicable taxing authority. The portion of the benefits associated with tax positions taken that exceeds the amount measured as described above is reflected as a liability for unrecognized tax benefits in the accompanying consolidated balance sheets along with any associated interest and penalties that would be payable to the taxing authorities upon examination. Upon the adoption of the Financial Accounting Standards Board (FASB) - issued guidance at July 1, 2008, and as of each subsequent fiscal year-end, there were no unrecognized tax benefits identified and recorded as a liability. Form 990 filed by the Hospital is subject to examination up to three years from the extended due date of each return. 1 1 1 X 1 X 600.000000000000 1 1 1 0 1 1 4839431 4839431 0.04470 42421963 53309723 -10887760 0.00000 47261394 53309723 -6048329 0.04470 330459 223674 106785 0.00100 1731911 1550373 181538 0.00170 2062370 1774047 288323 0.00270 49323764 55083770 -5760006 0.04740 1 11421745 1158663 24731425 24609509 121916 X 1 1 1 Century PHO Inc To obtain and manage contracts with health maintenance organizations 0.50000 0.50000 2 Family Health Network Inc Provider of managed health care services for the indigent 0.20000 1 1 Norwegian American Hospital Inc

1044 N Francisco Chicago IL 60660

X X Norwegian American Hospital Inc 1 1 1 200.000000000000 1 600.000000000000 1 X X X X X X 1 0 1 0 1 X 1 0 Part I, Line 3c: Norwegian American Hospital uses the FPG to determine free and discounted care. Patients with eligible assets and income above the 200%, but not exceeding 600% of FPG, adjusted for family size, will receive a discount on medically necessary services provided to them, based upon a sliding scale established by hospital policy. Part I, Line 6a: Norwegian American Hospital prepared an annual Community Benefit Report which is submitted to the Attorney General of the State of Illinois. Part I, Line 7: The costing methodology used to calculate the amounts reported in the table is the cost-to-charge ratio derived from the IRS's Schedule H, Worksheet 2. Part I, Line 7g: Norwegian American Hospital did not include any costs attributable to a physician clinic as Subsidized Health Services. Part I, L7 Col(f): There was a total of bad debt expense of $11,421,745 subtracted from total expenses. Part II: In addition to providing quality inpatient and outpatient services, Norwegian American Hospital reaches beyond its walls and into communities through an array of activities and programs designed and delivered to benefit the communities it serves. These community benefits include: - Care that is provided free, subsidized or without full reimbursement from Medicare, Medicaid or other government insurance programs. -Services responding to unique community needs, such as diabetes services, emergency care, behavioral health services, substance abuse, Pediatric Care-A-Van; as well as health screenings, immunization programs, school-based health care and other community outreach programs. -Education to train physicians, nurses, radiology technicians, and other highly skilled health care professionals. -Volunteer services provided by hospital employees who volunteer in their communities and community members who volunteer at the hospital.-Language-assistance services, such as translators, signage, forms, brochures, patient education materials and other information in languages other than English. -Donations by Norwegian American Hospital of meeting and clinic space, as well as other assistance to community groups. Part III, Line 4: The cost methodology used to calculate the amount reported as Bad Debt Expense, at cost, is the cost-to-charge ratio derived from the IRS's Schedule H, worksheet 2.Audited Financial Statements footnote regarding bad debt expense:The collection of receivables from third-party payors and patients is the Hospital's primary source of cash for operations and is critical to its operating performance. The primary collection risks relate to uninsured patient accounts and patient accounts for which the primary insurance payor has paid, but patient responsibility amounts (deductibles and copayments) remain outstanding. Patient receivables from third-party payors are carried at a net amount determined by the original charge for the service provided, less an estimate made for contractual adjustments or discounts provided to third-party payors and an allowance for uncollectible accounts, if necessary. Patient receivables due directly from patients are carried at the original charge for the service provided less discounts provided under the Hospital's charity care policy, less amounts covered by third-party payors and less an estimated allowance for doubtful receivables. In evaluating the collectibility 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 uncollectible accounts and provision for uncollectible accounts. Management regularly reviews data about these major payor sources of revenue in evaluating the sufficiency of the allowance for uncollectible accounts. 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 uncollectible accounts in the period of service on the 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 uncollectible accounts.The Hospital's allowance for uncollectible accounts for self-pay patients was approximately 71 percent of self-pay accounts receivable at September 30, 2012 and 2011. The Hospital's self-pay write-offs were $8,541,144 and $8,598,927 for fiscal year 2012 and 2011, respectively. The Hospital has not changed its charity care or uninsured discount policies during fiscal years 2011 or 2012. The Hospital does not maintain a material allowance for uncollectible accounts from third-party payors, nor did it have significant write-offs from third-party payors.Receivables or payables related to estimated settlements on various contracts in which the Hospital participates are reported as amounts due from or to third-party programs. Part III, Line 8: Costing Methodology used is the Medicare cost report which utilizes a step-down method of cost allocation. This order of allocation for overheads has been predetermined by Medicare and is printed out on the cost report.The most common overhead is allocated first to all other overheads and the patient care cost centers. Then that cost center is closed and the next most common overhead is allocated. This is continued until all the overheads are allocated out. Part III, Line 9b: The written debt collection policy and practice are that once the charity care application has been approved, the collection practice is stopped and the patient is notified in writing. Norwegian American Hospital, Inc. Part V, Section B, Line 19d: 40% of standard billing rate. Norwegian American Hospital, Inc. Part V, Section B, Line 20: Norwegian American Hospital, Inc. (NAH) takes its commitment to serving the uninsured and underinsured members of its community very seriously and as a result has implemented a financial assistance policy that meets the requirements of Illinois Public Act 095-0965 "Hospital Uninsured Patient Discount Act". This State Law was enacted with an effective date of April 1, 2009 and required that hospitals offer uninsured patients who met the minimum financial requirements (i.e. earnings less than 600% of the FPG and certain asset limitations) a rate equal to 135% of the hospital's most recently filed Medicare cost to charge ratio. This policy was also extended to all clinically necessary procedures and was not limited to emergency care only. Using the FPG, we created a set of discounts for patients without insurance that ranged from free care for those who earned less than 200% of the FPG to a 60% discount off of regularly billed charges for any uninsured patient who earned less than 600% of the FPG. Because our financial assistance policy so generously extends to patients who earn up to 600% of the FPG, it is possible that those patients could be responsible for charges that exceed an individual with insurance. If this situation arose, Norwegian American Hospital, Inc. would make every effort to work with the patient to limit their liability to a reasonable amount. Part VI, Line 2: Norwegian American Hospital's Community Benefit Plan was developed to establish strategies for improving access to care and positively affecting the health of the communities that it serves. Additionally, the Plan sets the course for strengthening existing partnerships and building new ones with individuals and organizations within Norwegian American Hospital's primary service areas in order to leverage and maximize the impact of its programs. Development of the plan is derived through the Strategic Planning of Norwegian American Hospital's Board of Trustees and through organizational involvement in community partnerships. The goals developed for planning community services involved meeting with physicians and community partners to determine where the gaps of care and services could be filled through Norwegian American Hospital involvement. In developing its Community Benefits Plan, Norwegian American Hospital set the following goals:1) Serve as a catalyst/convener for the Obesity and Diabetes initiatives in Humboldt Park2) Host community-based education events such as ESL, life skills training, job seeking skills, etc. 3)Promote initiatives that enhance access to health care for the uninsured and underinsured. 4)NAH Leadership to assume an active role in community based organizations Boards, Task Forces and Community Events Part VI, Line 3: Norwegian American Hospital informs and educates patients and persons, who may be billed for patient care, about their eligibility for assistance under federal, state or local government programs or under the organization's charity care policy on its intranet and through flyers. Part VI, Line 4: Norwegian American Hospital serves a Primary Community Area and a Secondary Community Area. The Primary Community Area consists the following areas, zip codes and population: -Austin-Belmont-Cragin-Hermosa-Humboldt Park-Logan Square-West Town-Avondale-Irving Park-North Center-East Garfield Park-West Garfield Park-North Lawndale White Hispanic African-AmericanPrimary Zip Codes Population - Perecentage60618 26,023 37% 42,597 60% 2,392 3%60622 15,379 40% 18,385 48% 4,634 12%60624 1,032 4% 244 1% 25,798 95% 60639 6,124 7% 60,432 74% 15,295 19%60647 14,923 21% 51,598 73% 4,173 6% 60651 2,703 14% 16,294 83% 708 4%The Primary Secondary Area consists the following areas, zip codes and population: -Archer Heights-Brighton Park-Gage Park-Garfield Ridge-West Elsdon-South Lawndale-Portage Park-Pullman White Hispanic African-AmericanSecondary Zip Codes Population - Perecentage60612 5,071 24% 2,800 13% 13,682 63%60623 1,175 1% 58,174 67% 27,111 31% 60628 2,252 3% 1,838 3% 66,955 94%60632 13,641 20% 49,881 75% 3,323 5%60641 28,875 54% 23,567 44% 1,025 2%60644 2,057 5% 598 1% 38,526 94%60804 10,122 17% 48,680 81% 1,245 2%Norwegian American Hospital's Age for the fiscal year was as follows:Age %0 16%1-19 4%20-64 68%65-84 11%85-99 2%100+ 0%Norwegian American Hospital's Race and Ethnicity for the fiscal year was as follows:Race %American Indian or Alaska 0%Asian 1%Black or African American 43%White 10%Other 46%EthnicityHispanic 47%Non-Hispanic 53% Reports Filed With States Part VI, Line 7 IL X X X X 0 0 0 0 0 0 0 0 0 Jose R Sanchez 449455 0 202000 0 17939 0 11000 0 54238 0 734632 0 0 0 Anthony Evers 187114 0 0 0 0 0 0 0 15256 0 202370 0 0 0 Matthew J Lambert III 264057 0 10000 0 3957 0 0 0 22381 0 300395 0 0 0 Carrie L Smith 243455 0 0 0 274 0 4874 0 19788 0 268391 0 0 0 Murali Vinta 271007 0 0 0 273 0 0 0 22351 0 293631 0 0 0 Cesar A Carranza 218344 0 0 0 2697 0 0 0 17743 0 238784 0 0 0 Kenneth Moore 177005 0 0 0 1798 0 3700 0 15021 0 197524 0 0 0 Qaiser Jamal 178120 0 0 0 231 0 3606 0 14641 0 196598 0 0 0 Illinois Finance Authority Revenue Bonds Series 2008 861091967 45200FMQ9 2008-08-15 4500000 See Part V 0 0 0 Illinois Finance Authority Revenue Bonds Series 2008 861091967 45200FMS5 2008-08-15 5000000 See Part V 0 0 0 Illinois Finance Authority Revenue Bonds Series 2008 861091967 45200FMT3 2008-08-15 14450000 See Part V 0 0 0 4500000 798333 1159612 157619 2384436 2008 1 0 1 1 5000000 798334 1159612 157619 2884435 2008 1 0 1 1 14450000 798333 1159311 157620 12334436 2008 1 0 1 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Schedule K, Part I, Line A, B, and C Column (f) - Description of Purpose: The Series 2008 bond proceeds, together with other available funds, were used to refund the outstanding principal amounts of certain bonds in the amount of $3,467,000, to pay or reimburse the Hospital for the payment of the cost of acquiring, constructing and equipping certain of the Hospital's health care facilities, to fund a debt service reserve fund for the benefit of the Series 2008 bonds, and to pay certain expenses incurred in connection with the issuance of the Series 2008 bonds. Timothy Egan Family member of Duke Miglin, Trustee 103197 Timothy Egan is an employee of Norwegian American Hospital. 0 Form 990, Part VI, Section B, line 11 The Form 990 is reviewed by members of the Fiscal Service department, followed by a review of the Chief Financial Officer and the Chief Executive Officer. Form 990, Part VI, Section B, line 12c All Trustees, Officers, and key employees and key physicians (as defined in the Board's Conflict of Interest Policy) of the Corporation are subject to the conflict of interest policy. In addition, all independent contractors who provide services and/or materials to the Corporation in exchange for $20,000 or more in payment during any fiscal year shall be subject to these provisions. All persons subject hereto shall be hereinafter referred to as "Covered Persons." The Chief Executive Officer of the Corporation is responsible for publicizing the provisions of this Article to the persons affected thereby. No person shall become a Trustee, Officer, or Employee or Medical Department Director of the Corporation without first acknowledging in writing to the Corporation that he or she has reviewed, fully understands and is in compliance with the provisions of the conflict of interest policy. All Covered Persons shall promptly disclose to the Board of Trustees of the Corporation all substantive potential conflicts of interest which such person discovers or which is brought to his or her attention. Such disclosure shall include submission to the Board of a written statement of the facts surrounding the conflict of interest and an opportunity to make a brief oral statement to the Board with respect to the matter in question. An annual disclosure statement shall be circulated to all Covered Persons to assist them in considering such disclosures. In addition, the policy in monitored periodically throughout the year for any conflicts of interest. Prompt disclosure notices of conflict shall be filed with the President of the Corporation or any other person designated by him from time to time to receive such notifications. All disclosure notices received hereunder shall be noted for record in the minutes of a meeting of the Board of Trustees. The presence of the Trustee who is directly or indirectly a party to the transaction in question or a Trustee who is otherwise not disinterested may be counted in determining whether a quorum is present for the purpose of the meeting, but shall not be present or have a vote when the Board of Trustees or a committee of the Board discusses and takes action on the transaction. In order to determine the pay level of an executive employee, Norwegian American Hospital utilizes wage data from a variety of sources including Metropolitan Chicago Health Care Council, Integrated Healthcare Services and Sullivan and Cotter. Compensation rates are determined based on the relevant experience and education of the candidate as compared to average survey ranges. Additional information on market conditions is obtained as needed via other published sources. Executive Recruitment firms, if engaged, can provide data regarding the market rates for executives with comparable experience and assist in establishing total compensation packages during the offer process. Form 990, Part VI, Section C, line 19 Norwegian American Hospital, Inc makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Loss from Centennial Medical Management Corp. -42,431. Income from investments in joint ventures 704,028. Pension related changes, other than net periodic pension cost -1,824,661. Foundation net income -91,191. Total to Form 990, Part XI, Line 5: -1,254,255. Norwegian American Hospital Foundation 1044 North Francisco Ave Chicago IL 60622 363257131 Supporting Foundation IL 501(c)(3) Line 11a, I Norwegian American Hospital 1 Centennial Medical Management Corporation 1044 North Francisco Ave Chicago IL 60622 363394548 Outpatient Pharmacy IL Norwegian American Hospital Inc C 254497 772290 1.00000 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 Norwegian American Hospital Foundation C 244439 Book Value Centennial Medical Management Corporation R 254497 Book Value