2013-11-15T11:56:52-06:00 2012-12-31 BKD LLP 111 South Tejon Suite 800 Colorado Springs CO 809039848 990 2012-01-01 860096775 Community Hospital Association Inc % THE ORGANIZATION COMM 9286844390 520 Rose Lane Suite Wickenburg AZ 85390 Ron Smith 9286844390 2013-11-15 true 7194714290 2012 2016-03-07 17:11:31Z Jim Tavary 520 Rose Lane Wickenburg AZ 85390 18436655 false X www.wickhosp.com X 1946 AZ To provide quality health and wellness services where the patient, family and community come first. 9 9 212 85 12664 279358 316115 15471509 18004452 22232 13005 205013 -84640 15978112 18248932 0 0 0 0 9044336 10502401 0 0 0 8238571 9152446 17282907 19654847 -1304795 -1405915 17181960 15899677 9028005 9311418 8153955 6588259 TO PROVIDE QUALITY HEALTH AND WELLNESS SERVICES WHERE THE PATIENT, FAMILY, AND COMMUNITY COME FIRST. false false 16792573 0 17759275 Provide inpatient and outpatient diagnostic and therapeutic health care services to the residents and visitors of greater Wickenburg, Arizona, a rural community of approximately 23,000. 396659 0 240853 Provide Fitness Center for residents and visitors of greater Wickenburg, Arizona, promoting a wellness environment for the community. 17189232 true true false false false false false false false true true false false false true false true false false false false false false false false false true true false false true true false false false false false false false false false false false false false false false true true true false false true 58 0 true 212 true true true false false false false false false false false false false false false X 9 9 false false false false false false false true true false false true true true true false true false false false AZ X THE ORGANIZATION 9286844390 520 ROSE LANE Wickenburg AZ 85390 UWE GROSS 1.0 X X BOB MCCOY 1.0 X X KEVIN ARMSTRONG 1.0 X X GARY TURNER 1.0 X X DENNIS BARRACO DO 1.0 X SALLIE HERSHKOWITZ 1.0 X RICHARD ABBUHL 1.0 X JOHN SNAVELY 1.0 X HANK BRUBAKER 1.0 X ROXIE GLOVER 1.0 X JIM TAVARY 39.0 1.0 X 175399 15136 JAMES SMITH 39.0 1.0 X 157057 0 6536 WILLIAM FIRTH MD 40.0 X 259313 45389 ANAGHA DESCHMUKH 40.0 X 151628 11172 MARILYN HALDER MD 40.0 X 181658 25535 TODD KRAVETZ MD 40.0 X 236713 30330 KAREN LOTTIS 40.0 X 154585 6359 ROGER ROSE 40.0 X 163791 10626 1480144 0 151083 11 false true false Emergency Physicial Professional As 1470 W Port Au Prince Lane PHOENIX AZ 85023 PHYSICIANS 648000 Medical Diagnostic Imaging Group L PO Box 17049 PHOENIX AZ 85011 MEDICAL IMAGING 439498 Comp-Ray 205 W Deer Valley Rd PHOENIX AZ 85027 Med Equip Service 338570 CPSI PO Box 850309 MOBILE AL 36685 Software Support 225080 Alliance Imaging File 55826 LOS ANGELES CA 90074 Medical Imaging 216732 11 309143 6972 316115 MEDICARE 621990 8639608 8639608 PATIENT SERVICES 621990 7955251 7955251 EHR INCENTIVE PAYMENTS 621990 429184 429184 WELLNESS CENTER 621990 240853 240853 340B DRUG PRICING PROGRAM REVENUE 621990 730072 730072 9484 9484 18004452 20041 20041 0 0 73724 180687 -106963 0 -106963 12664 -119627 0 7036 -7036 -7036 -7036 0 0 0 OTHER REVENUE 900099 22323 5160 17163 22323 18248932 18000128 12664 -79975 X 0 0 0 0 658650 522813 135837 0 8135820 7293107 842713 0 1082098 970014 112084 625833 556621 69212 0 57223 57223 102358 102358 0 0 0 2049263 1763980 285283 68178 68178 324642 244028 80614 212523 212523 0 222852 215427 7425 57543 47073 10470 0 132952 130314 2638 516977 516977 0 1230669 1221147 9522 223956 223956 MEDICAL SUPPLIES 2280707 2280707 PROVISION FOR BAD DEBTS 948591 948591 REPAIRS & MAINTENANCE 430364 404488 25876 0 MISCELLANEOUS 293648 154443 139205 19654847 17189232 2465615 0 X 1358734 499550 52758 55906 0 0 2757013 2758580 0 0 0 0 694900 657620 280569 460101 345879 289036 21674933 11569051 10658129 10105882 489656 485931 0 0 0 0 0 0 544322 587071 17181960 15899677 1316453 1893582 0 0 0 0 5570000 5465000 0 0 0 0 2073661 1884481 0 0 67891 68355 9028005 9311418 X 8055320 6451072 98635 137187 0 0 8153955 6588259 17181960 15899677 X -1405915 -159781 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 98635 217877 179325 137187 26885 397587 325837 98635 68115 1000 -3500 38730 26885 116962 -16413 32434 68115 1146828 5000 -8423 1026443 116962 0.00000 0.00000 1.00000 false true true 1199482 1199482 13051924 6839680 6212244 5000 926 4074 6189604 4236697 1952907 1228923 491748 737175 10105882 0 INSURANCE FINANCING 68355 68355 17321247 180687 180687 17140560 1108372 1108372 18248932 18886943 180687 180687 18706256 948591 948591 19654847 Intended use of the organization's endowment funds Part, V, Line 4 The endowment funds are to be used for educational purposes and to acquire property & equipment for the hospital. Other revenue included on books, not on return part XI, Line 2d Rental Expense reclassed from expense to revenue 180,687 Other revenue included on return, not on books Part XI, Line 4b Provision for uncollectable accounts reclassed to expense 948,591 Change in interest in net assets of wickenburg community hospital foundation 159,781 Total 1,108,372 Other expense included on books, not on return Part XII, Line 2d Rental Expense reclassed from expense to revenue 180,867 Other expense included on return, not on books Part XII, Line 4b Provision for uncollectable accounts reclassed to expense 948,591 Uncertain Tax Positions Part X, Line 2 MANAGEMENT HAS EVALUATED THEIR INCOME TAX POSITIONS UNDER THE GUIDANCE INCLUDED IN ASC 740. BASED ON THEIR REVIEW, MANAGEMENT HAS NOT IDENTIFIED ANY MATERIAL UNCERTAIN TAX POSITIONS TO BE RECORDED OR DISCLOSED IN THE FINANCIAL STATEMENTS. true true X true X true X true true false false 135048 0 135048 0.00720 1141758 863936 277822 0.01490 1276806 863936 412870 0.02210 396659 240853 155806 0.00830 44722 24859 19863 0.00110 441381 265712 175669 0.00940 1718187 1129648 588539 0.03150 true 948591 474296 6202657 6202657 X true false 1 1 Wickenburg Community Hospital

520 Rose Lane Wickenburg AZ 85390

www.wickhosp.com X X Wickenburg Community Hospital 1 false true true 200. true 400. true X X X X X true true X X true false X X X X true X false false 2 Community Hospital Clinic - WICKENBURG

519 Rose Lane Wickenburg AZ 85390

PRIMARY CARE CLINIC RURAL HEALTH CLINIC Community Hospital Clinic - Congress

26750 S Santa Fe Road Suite B Congress AZ 85332

PRIMARY CARE CLINIC RURAL HEALTH CLINIC SCHEDULE H, PART I, LINE 7, COLUMN F BAD DEBT EXPENSE TOTAL BAD DEBT EXPENSE REMOVED FROM THE DENOMINATOR PRIOR TO THE PERCENTAGE CALCULATION = 948,591. SCHEDULE H, PART I, LINE 7 CALCULATION OF COMMUNITY BENEFIT EXPENSES The organization used a cost-to charge ratio for lines 7a, 7b & 7g. The cost-to-charge ratio was derived from Worksheet 2, Ratio of Patient Care Cost-to-Charges. The information for line 7e was derived from information in the general ledger and other financial data related specifically to the various types of community benefits. SCHEDULE H, PART III, LINE 4 BAD DEBT EXPENSE Accounts receivable are reduced by an allowance for doubtful accounts. In evaluating the collectability of accounts receivable, the Hospital analyzes its past history and identifies trends for each of its major payer sources of revenue to estimate the appropriate allowance for doubtful accounts and provision for bad debts. Management regularly reviews data about these major payer sources of revenue in evaluating the sufficiency of the allowance for doubtful accounts. For receivables associated with services provided to patients who have third-party coverage, the Hospital analyzes contractually due amounts and provides an allowance for doubtful accounts and a provision for bad debts, if necessary (for example, for expected uncollectible deductibles and copayments on accounts for which the third-party payer has not yet paid, or for payers 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 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 or provided by policy) and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowance for doubtful accounts. The Hospital's allowance for doubtful accounts for self-pay patients decreased from 100% of self-pay accounts receivable at December 31, 2011, to 55% of self-pay accounts receivable at December 31, 2012. The Hospital's write-offs increased approximately $352,000 from approximately $608,000 for the year ended December 31, 2011, to approximately $960,000 for the year ended December 31, 2012. Despite the increase in write-offs, allowances decreased due to an effort during 2012 to write-off older accounts receivable balances deemed to be uncollectible. Bad Debt Expense is determined using the methodology as described in the note to the financial statements as shown above. Most of the bad debt expense results from uninsured patients receiving services primarily through the Emergency Room. The Director of Patient Financial Services estimates that approximately 50% of all bad debt would qualify for charity care, but it is difficult to get the patients to complete the Financial Assistance application. SCHEDULE H, PART III, LINE 8 MEDICARE The Medicare allowable costs is derived from the Medicare Cost Report. As a Critical Access Hospital, Medicare pays our allowable cost plus 1% including Medicare bad debts; therefore there is no Community Benefit for underpayments. SCHEDULE H, PART III, LINE 9B DEBT COLLECTION POLICY Although our collection policy does not address how patients who may qualify for charity care or financial assistance, our practice is to provide all patients at time of registration who do not demonstrate the ability to pay for the anticipated services (no insurance, no deposit, etc.) an opportunity to complete a charity application. Often, the charity application is not returned and charity is not recorded. In that event, the collection policy remains the same for those potential charity cases and all avenues of collection are pursued, just as if the charity application had not been offered. While we believe many or most of the charity cases end up as a bad debt, it is not for lack of effort to educate the potential charity applicant of the availability of assistance and keep the amounts out of our bad debt category. We further believe that many or most of these cases do not consider the impact on their financial credit rating and therefore do not return the application and the supporting documentation to complete the charity funding, and ignore the attempts to collect the medical billings. SCHEDULE H, PART VI NEEDS ASSESSMENT Community Hospital Association, Inc. continually accesses the community's medical needs through the relationship of our staff to community leaders and community programs that identify community needs, often medical in nature. Although the hospital is not always in a position to expand services and meet all identified needs, maintaining a core menu of services that meets the greatest community need has and continues to direct our strategic planning. SCHEDULE H, PART VI PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE All uninsured and under-insured patients at time of registration are provided with options available in our community for payment of the services provided. This is most often verbal with a written Charity Care Application. SCHEDULE H, PART VI COMMUNITY INFORMATION Wickenburg Community Hospital serves a primary service area population of approximately 17,000 in a rural service area clustered around Wickenburg, AZ. Wickenburg Community Hospital is the only hospital in the service area. The distribution of service area population by age is 0-17, 21%; 18-44, 25%; 45-64, 29%; 65+, 24%. The service area is home to a great number of winter residents, changing the population significantly from summer months to winter months, when the population grows by approximately 40%. SCHEDULE H, PART VI PROMOTION OF COMMUNITY HEALTH Wickenburg Community Hospital, designated as a Critical Access Hospital, serves a rural population approximately 35 miles west of the urban area of the greater Phoenix market place of Surprise, AZ. While the distance is not overly great, many of our patients come from rural areas west and north of Wickenburg, requiring them to drive much greater distances to obtain health care services if Wickenburg Community Hospital were not available to them. The most important service we provide is our Emergency Services and could not exist without our Critical Access Hospital status. Additionally, our Rural Health Clinic provides access to primary care providers in our community that probably would not exist if the hospital did not employ these providers. The availability of diagnostic services locally is very important to our community as a higher average age exists in our community, making it difficult to drive longer distances and spend a greater amount of time in obtaining diagnostic services required by their primary care providers. SCHEDULE H, PART V, LINE 20d During our budget planning process each year we decide, based upon the financial picture for the hosptial, the amount of financial aid that can be planned for eligible individuals for emergency and other medically necessary care. We recognize the majority of bad debts originate in the Emergency Room and plan accordingly, however the maximum amount allowed may exceed the amount planned, based on the operational performance during the year. The Federal poverty guidelines are used in determining the additional adjustments to amounts billed for FAP elgible individuals. X false true X X false false false false false false false false true false JIM TAVARY 175399 0 0 0 15136 190535 0 JAMES SMITH 154793 0 0 0 2264 0 0 0 6536 0 163593 0 0 0 WILLIAM FIRTH MD 245755 13558 0 15500 29889 304702 0 ANAGHA DESCHMUKH 145859 0 5769 0 11172 162800 0 MARILYN HALDER MD 181521 137 0 7750 17785 207193 0 TODD KRAVETZ MD 236713 0 0 7750 22580 267043 0 KAREN LOTTIS 154585 0 0 0 6359 160944 0 ROGER ROSE 163791 0 0 0 10626 174417 0 PART I, QUESTION 1B REIMBURSEMENT OR PROVISION OF EXPENSES Golf Club Membership: The Community Hospital Association pays golf club membership dues for James R. Smith, CFO, and James F. Tavary, CEO. A portion of the club dues are treated as taxable income based on a ratio of personal to business use. The personal use of the membership dues are reported on their W-2's. PART I, QUESTION 8 PAYMENTS MADE PURSUANT TO AN INITIAL CONTRACT EXCEPTION MR. TAVARY IS QUALIFIED BY TRAINING AND EXPERIENCE TO ACT AS CHIEF EXECUTIVE OFFICER OF THE ORGANIZATION. DUTIES SHALL BE PERFORMED TO THE BEST OF MR. TAVARY'S ABILITY, EXPERIENCE, AND TALENT TO THE REASONABLE SATISFACTION OF THE ORGANIZATION. BASE COMPENSATION IS PAID FOR SERVICES, WITH THE ELIGIBILITY OF PERFORMANCE BASED BONUSES. THE TERM OF THE CONTRACT SHALL BE THREE YEARS, WITH THE POSSIBLITY OF EXTENSION MADE BY MUTUAL AGREEMENT OF THE ORGANIZATION AND MR. TAVARY. PART I, QUESTION 9 REBUTTABLE PRESUMPTION PROCEDURE THE ORGANIZATION FOLLOWS THE REBUTTABLE PRESUMPTION PROCEDURE, HOWEVER, THE COMPARABILITY DATA USED IS NOT DOCUMENTED, THEREFORE QUESTION 9 IS ANSWERED AS NO. A ARIZONA HEALTH FACILITIES AUTHORITY 860453292 040507GK5 2005-06-09 6000000 CAPITAL PROJECTS AND EQUIPMENT false false false A 535000 0 6072257 492771 72257 0 120000 0 0 5390100 0 0 2007 false false true true A false false false false 0.00000 0.00000 0.00000 false false 0.00000 false false A false false false false false false 0 false 0 false true A true PART VI, LINE 2C 0 THE REBATE COMPUTATION WAS PERFORMED ON JUNE 8, 2010 FOR THE PERIOD JUNE 9, 2005 TO MARCH 31, 2010. 990 Review Process Part VI, Line 11b The Form 990 is prepared by a third party and is reviewed by the CFO. A copy of the 990 is made available to the governing board prior to filing with the IRS. Describe how conflict of interest policy is monitored & enforced Part VI, Line 12c All Board members are covered under the policy. Each Board Member must review the policy and sign a compliance certificate annually. The Board reviews the compliance certificates to determine if any conflicts exist. Conflicts are reviewed at the Board level. Any Board member who may have a conflict in any discussion is recused from the discussion and voting on the issue. Describe process for determining compensation Part VI, Question 15a The Board Chairman, with consultation of other members of the Board, reviews independent survey data acquired through the Arizona Hospital & Healthcare Association on executive salaries and reviews the performance of the CEO. This review is done annually by the Board in Executive Session. Describe process for determining compensation Part VI, Question 15b The CEO and HR Director use the Arizona Hospital & Healthcare Association survey data to review all positions in the facility, including key employees and other officers. Describe how documents are made available to the public Part VI, Line 19 Governing documents, conflict of interest policy, and financial statements are made available to the public by a formal request in writing. Other Changes to Net Assets Part XI, Line 9 Change in interest in net assets of wickenburg community hospital foundation (159,781) OTHER FEES FOR SERVICES FOR NON-EMPLOYEES FORM 990 PART IX LINE 11G DESCRIPTION:PHYSICIAN FEES TOTAL FEES:1054361 OTHER FEES FOR SERVICES FOR NON-EMPLOYEES FORM 990 PART IX LINE 11G DESCRIPTION:SPECIALISTS TOTAL FEES:225348 OTHER FEES FOR SERVICES FOR NON-EMPLOYEES FORM 990 PART IX LINE 11G DESCRIPTION:PURCHASED SERVICES TOTAL FEES:705541 OTHER FEES FOR SERVICES FOR NON-EMPLOYEES FORM 990 PART IX LINE 11G DESCRIPTION:340B MANAGEMENT FEE TOTAL FEES:20926 OTHER FEES FOR SERVICES FOR NON-EMPLOYEES FORM 990 PART IX LINE 11G DESCRIPTION:RECRUITING TOTAL FEES:43087 Wickenburg Community Hospital Foundation 520 Rose Lane Wickenburg AZ 85390 742521618 Fundraising AZ 501(C)(3) Line 7 NA true Wickenburg Community Hospital Auxiliary 520 Rose Lane Wickenburg AZ 85390 866056824 Support Org AZ 501(C)(3) 11 TYPE III NA false false false true true false false false false false false false false true true true false true false false WICKENBURG COMMUNITY HOSPITAL FOUNDATION C 279143 AMOUNT RECEIVED WICKENBURG COMMUNITY HOSPITAL FOUNDATION D 179483 LOAN AMOUNT WICKENBURG COMMUNITY HOSPITAL FOUNDATION Q 489668 ACTUAL AMOUNT