2013-05-14T14:30:27-05:00 2012-09-30 390758449 WIPFLI LLP 3703 OAKWOOD HILLS PARKWAY EAU CLAIRE WI 54701 990 2011-10-01 390938661 BURNETT MEDICAL CENTER INC BURN 7154635353 257 WEST SAINT GEORGE AVENUE GRANTSBURG WI 54840 CHARLIE FAUGHT 7154635353 2013-05-14 1 HOLLY POKRANDT CPA P00449155 7158323407 2013-05-14 2011 2016-02-24 21:20:13Z CHARLES FAUGHT 257 WEST SAINT GEORGE AVENUE GRANTSBURG WI 54840 22016320 0 X BURNETTMEDICALCENTER.ORG X 1957 WI THE MISSION OF BURNETT MEDICAL CENTER IS TO PROVIDE COMPASSIONATE, COMPREHENSIVE, COMMUNITY HEALTHCARE THAT EXCEEDS OUR CUSTOMER'S EXPECTATIONS. OUR MISSION, AS WELL AS OUR VISION AND VALUES, SERVES AS A GUIDELINE FOR DAILY DECISION MAKING AND REPRESENTS THE PRINCIPLES AND PRACTICES THAT WE CONSTANTLY APPLY. THE COMFORT AND CARE OF OUR PATIENTS IS A MAJOR FOCUS OF OURS. WE WANT TO BE THE HEALTHCARE PROVIDER OF "CHOICE" - PROVIDING EXPERT AND COST EFFECTIVE CARE IN A "HOMETOWN" ATMOSPHERE. ANOTHER OBJECTIVE OF OURS IS TO PROVIDE EDUCATION THAT WILL INCREASE HEALTH AWARENESS. PART OF OUR MISSION IS TO CONTINUALLY PUT THE "CARE" IN HEALTHCARE. MORE HEALTHCARE INFORMATION IS NOW AVAILABLE FROM OUR WEB SITE, WHICH ALSO PROVIDES PATIENT EDUCATION RESOURCES FOR THOSE WE SERVE. 7 7 275 11 0 0 72665 109997 20223455 20915637 19262 22315 0 0 20315382 21047949 0 0 0 0 10855720 10951133 0 0 0 9786908 9512968 20642628 20464101 -327246 583848 24268848 24595241 16965800 16655581 7303048 7939660 X THE MISSION OF BURNETT MEDICAL CENTER IS TO PROVIDE COMPASSIONATE, COMPREHENSIVE COMMUNITY HEALTHCARE. 0 0 11914708 12825669 BURNETT MEDICAL CENTER, LOCATED IN RURAL NORTHWEST WISCONSIN IS A 17 BED CRITICAL ACCESS HOSPITAL THAT PROVIDES THE FOLLOWING SERVICES THROUGHOUT A THREE COUNTY REGION:ACUTE CARE HAS 50+ EMPLOYEES WHO ALSO WORK IN OBSTETRICS, OPERATING ROOM, EMERGENCY ROOM, AND POST ANESTHESIA RECOVERY. WE PROVIDE GENERAL INPATIENT MEDICAL AND SURGICAL CARE, AS WELL AS A LARGE VOLUME OF OUTPATIENT SERVICES WHICH INCLUDE: OP SURGERY, CHEMOTHERAPY, BLOOD TRANSFUSION, IV THERAPY AS EXAMPLES. ALL OF THE RN STAFF IS ACLS ACCREDITED AND THE ENTIRE STAFF IS CERTIFIED IN CPR. THE GOAL OF THE NURSING STAFF IS TO PROVIDE EXCELLENT PATIENT CARE, CLOSE TO HOME, NEAR FAMILY AND FRIENDS.WE ALSO PROVIDE A FULL RANGE OF SERVICES FROM A 24/7 EMERGENCY ROOM TO CARDIAC REHABILITATION, AND WE PROVIDE OTHER THERAPEUTIC AND DIAGNOSTIC SERVICES VIA RADIOLOGY, LAB, PHYSICAL THERAPY, AND OCCUPATIONAL THERAPY.DURING FY 2012 IN A TOTAL OF 1,828 PATIENT DAYS WE SERVED 478 PATIENTS IN OUR INPATIENT AND SWING BED PROGRAMS AND ALSO HAD 43 BIRTHS. WE PERFORMED 718 SURGICAL PROCEDURES, SAW 4,755 PATIENTS IN EMERGENCY AND URGENT CARE, AND PROVIDED SERVICES FOR OVER 18,459 OTHER OUTPATIENT VISITS. GROSS HOSPITAL REVENUE OF $188,481 WAS PROVIDED AS CHARITY CARE TO 48 DIFFERENT PATIENTS FOR 224 EPISODES OF CARE.SINCE JUNE OF 2004, BURNETT MEDICAL CENTER HAS BEEN PARTICIPATING IN A PROGRAM DEVELOPED BY ABBOTT NORTHWESTERN HOSPITAL AND THE MINNEAPOLIS HEART INSTITUTE. THE LEVEL 1 HEART ATTACK PROGRAM IS AN INNOVATIVE APPROACH TO TREATING PATIENTS SUFFERING FROM A HEART ATTACK. THE KEY INGREDIENT FOR SUCCESS IS SPEED IN TREATMENT. THE GOAL IS TO TREAT AND TRANSPORT PATIENTS WITHIN 120 MINUTES, MEANING 120 MINUTES FROM THE TIME A PATIENT ENTERS THE EMERGENCY ROOM AT BURNETT MEDICAL CENTER UNTIL THE FIRST BALLOON IS INFLATED OR STENT PLACED AT ABBOTT NORTHWESTERN HOSPITAL (ABNW).BECAUSE RURAL HOSPITALS DO NOT HAVE THE CAPABILITY TO DO ANGIOPLASTY, IT IS IMPORTANT TO MOVE A HEART ATTACK PATIENT TO THE NEAREST HOSPITAL THAT HAS A HEART CATHETERIZATION LAB. THE LEVEL 1 PROGRAM HAS A DEFINITE PROTOCOL TO MOVE THESE PATIENTS QUICKLY DURING THAT "GOLDEN HOUR" WHEN ANGIOPLASTY IS THE MOST SUCCESSFUL.BURNETT MEDICAL CENTER IS ONE OF 30 HOSPITALS IN MINNESOTA AND WISCONSIN PARTICIPATING IN THE LEVEL 1 PROGRAM. CLEARLY, THE LEVEL 1 PROGRAM IS ADVANTAGEOUS TO RESIDENTS OF BURNETT COUNTY, KNOWING THAT CARDIOVASCULAR DISEASE IS THE LEADING CAUSE OF DEATH FOR MEN AND WOMEN IN THE UNITED STATES. THIS TEAM APPROACH GIVES PATIENTS THE ADVANTAGE OF TIME WHICH TRANSLATES TO BETTER OUTCOMES AND DECREASED MORTALITY. BURNETT MEDICAL CENTER'S MEDICAL AND NURSING STAFF HAVE BEEN TRAINED FOR THIS PROGRAM AND ARE PREPARED AND PLEASED TO PROVIDE QUICK ACCESS TO EFFICIENT CARDIAC CARE THROUGH THE LEVEL 1 HEART ATTACK PROGRAM. 2916409 4702807 BURNETT MEDICAL CENTER CLINIC IS LOCATED JUST OFF HIGHWAY 70 IN GRANTSBURG AND IS PART OF OUR EXPANDED FACILITY. THE CLINIC IS STAFFED BY 24 EMPLOYEES INCLUDING (5) PHYSICIANS, (1) PHYSICIAN ASSISTANT, (2) CERTIFIED NURSE PRACTITIONERS, AND (1) CERTIFIED NURSE MIDWIFE.WE ARE PLEASED TO OFFER OUR PATIENTS A RANGE OF SERVICES INCLUDING: PHYSICALS (INCLUDING WELL CHILD CHECKS, PRE-OPERATIVE, DOT, ETC.), OBSTETRICAL EXAMS, HEALTH STATUS ASSESSMENTS, DIAGNOSIS AND TREATMENT OF COMMON, ACUTE, AND CHRONIC HEALTH CONDITIONS, IMMUNIZATIONS, FAMILY PLANNING, DIABETIC EDUCATION, WOMEN'S HEALTH, COLONOSCOPY PROCEDURES, FRACTURE CARE, VASECTOMIES, ROUTINE LABORATORY TESTING, EKG'S, AND HOLTER MONITORING. ADDITIONALLY, THE CLINIC LABORATORY IS A CERTIFIED COLLECTION SITE FOR URINE DRUG SCREENING.HOURS OF OPERATION HAVE BEEN EXPANDED TO ALLOW PEOPLE INCREASED ACCESS, INCLUDING WORKING FAMILIES WITH SCHOOL-AGE CHILDREN, PEOPLE THAT WORK VARYING SHIFTS, ETC. OUR PROVIDERS HAVE COLLABORATIVE RELATIONSHIPS WITH AREA INDUSTRIES, INCLUDING THE LOCAL SCHOOL SYSTEMS. THIS ALLOWS BURNETT MEDICAL CENTER TO PROVIDE EDUCATIONAL OPPORTUNITIES TO EMPLOYEES OF THESE INDUSTRIES, INCLUDING BLOODBORNE PATHOGENS TRAINING, HEALTH EDUCATION TO SCHOOL CHILDREN, AND PARTICIPATION IN EMPLOYEE HEALTH FAIRS. BMC PROVIDERS PARTICIPATE IN THE LOCAL ROTARY GROUP AND IN COUNTY COALITIONS TO REDUCE PRESCRIPTION DRUG ABUSE AND IMPROVE AWARENESS OF WELLNESS ACTIVITIES IN THE AREA. WE ALSO SPONSOR AN ANNUAL 5K EVENT THAT RAISES FUNDS FOR A LOCAL CHARITY WHILE PROMOTING HEALTHY LIFESTYLES - THIS YEAR IS OUR 7TH ANNUAL!OVER 17,000 PRIMARY CARE CLINIC VISITS WERE PROVIDED DURING FY 2012. CLINIC CHARGES OF $23,023 WAS PROVIDED AS CHARITY CARE TO 48 DIFFERENT PATIENTS IN 197 VISITS. 3341880 3387161 THE CONTINUING CARE CENTER OF BURNETT MEDICAL CENTER OFFERS 46 SEMI-PRIVATE AND 4 PRIVATE ROOM ACCOMMODATIONS AND A FULL RANGE OF HEALTH AND PERSONAL CARE SERVICES. PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY ARE AVAILABLE, AS WELL AS NUTRITIONAL SERVICES, RECREATIONAL ACTIVITIES, AND SOCIAL SERVICES. ADDITIONALLY, ADULT DAY CARE AND RESPITE CARE IS AVAILABLE. THE GOAL OF THE CONTINUING CARE CENTER'S STAFF IS TO PROVIDE NECESSARY HEALTH SERVICES WHILE MAINTAINING AN ATMOSPHERE OF HOPE, HARMONY, HUMOR, AND A "HOME" AWAY FROM HOME.WE STRIVE TO ENHANCE THE QUALITY OF RESIDENTS' LIVES VIA A VENUE FOR COMMUNITY-BASED VOLUNTEERS SHARING THEIR TIME AND TALENT WITH OUR RESIDENTS, SUCH AS MUSICAL BANDS, ROTARY CLUB SPONSORED FUNCTIONS, ETC.DURING FY 2012 WE HAD 18,001 RESIDENT DAYS SERVING ABOUT 100 DIFFERENT RESIDENTS. 18172997 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 6 0 1 275 1 0 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X CHARLIE FAUGHT 7154635353 257 WEST SAINT GEORGE AVE GRANTSBURG WI 54840 JAMES RICHINSION II 0.50 X X 0 0 0 ADAM BENSON 0.50 X X 0 0 0 TIM GERBER 0.50 X 0 0 0 MARILYN KOOIKER 0.50 X X 0 0 0 JOLOUISE MCNALLY 0.50 X 0 0 0 PAT TAYLOR 0.50 X 0 0 0 RANDY CAREY 0.50 X 0 0 0 CHARLES FAUGHT 40.00 X 127130 0 5729 GORDON LEWIS 40.00 X 187599 0 6374 TIMOTHY NOVICK 36.00 X 298221 0 12676 ADEOLA JOLAYEMI 40.00 X 210141 0 2668 VESNA RADIVOJEVIC 40.00 X 173013 0 11947 MELINDA DEYE 31.00 X 125226 0 1726 1121330 0 41120 6 0 1 1 DR BLAISE P VITALE MD SC 257 WEST SAINT GEORGE AVENUE GRANTSBURG WI 54840 CLINIC AND ER SERVICES 310835 BNB ENTERPRISES 27165 JOHN STONE RD WEBSTER WI 54893 CRNA SERVICES 226255 ANTON MENTELE 923 BURGS PARK DRIVE SHELL LAKE WI 54871 CRNA SERVICES 220160 SURGERY CLINIC OF SPOONER N 6142 LITTLE VL ROAD SPOONER WI 54801 SURGICAL SERVICES 170000 4 21357 87000 1640 109997 HOSPITAL PATIENT SERVI 621990 12825669 12825669 CLINIC PATIENT SERVICE 621110 4702807 4702807 NURSING HOME RESIDENT 623000 3387161 3387161 20915637 25662 25662 965004 20 968371 0 -3367 20 -3347 -3347 21047949 20915637 0 22315 373952 373952 8600992 7529072 1071920 1388680 1224130 164550 587509 512880 74629 8979 8979 14035 14035 56013 56013 2614288 2492012 122276 74830 74830 2148571 2029292 119279 50336 50336 1080986 1080986 93926 68682 25244 1464512 1464512 72902 72902 BAD DEBT EXPENSE 1037018 1037018 REPAIRS & MAINTENANCE 499845 490080 9765 MEDICAID BED ASSESSMENT 174208 174208 DUES & SUBSCRIPTIONS 78440 27393 51047 44079 42732 1347 20464101 18172997 2291104 0 -23486 163323 2332770 3683770 3024925 3080975 530105 551396 610974 439899 25739186 11204429 15723059 14534757 1578246 1589542 220268 209524 271987 342055 24268848 24595241 1182281 1272348 15633066 15177056 150453 206177 16965800 16655581 X 7292531 7867490 10517 72170 7303048 7939660 24268848 24595241 X 583848 52764 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3494 3494 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: BURNETT MEDICAL CENTER, INC. PAYS ANNUAL ASSOCIATION MEMBERSHIPS TO THE AMERICAN HOSPITAL ASSOCIATION AND WISCONSIN HOSPITAL ASSOCIATION. THESE DUES ARE PRIMARILY FOR ACCESS TO EDUCATIONAL MATERIALS AND STAFF TRAINING AND DEVELOPMENT. A SMALL PORTION OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. 50000 50000 19731994 7140756 12591238 5957192 4063673 1893519 14534757 457(B) PLAN PAYABLE 198715 FLEXIBLE SPENDING ACCOUNT LIABILITY 7462 206177 21047949 20464101 583848 -8889 61653 52764 636612 21047949 0 21047949 0 21047949 20464101 0 20464101 0 20464101 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: SCHEDULE D PART XIV: INCOME TAXES IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE MEDICAL CENTER ASSESSES 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 TAX AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF TAX POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE MEDICAL CENTER RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2012 AND 2011. FEDERAL RETURNS FOR THE YEARS ENDED SEPTEMBER 30, 2009, AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. THE MEDICAL CENTER'S POLICY IS TO RECOGNIZE INTEREST AND PENALTIES RELATED TO INCOME TAX MATTERS IN INCOME TAX EXPENSE WHEN INCURRED. AS OF SEPTEMBER 30, 2012 AND 2011, THERE WERE NO MATERIAL TAX PENALTIES, OR INTEREST RELATED TO TAX PENALTIES, RECORDED BY THE MEDICAL CENTER IN THE FINANCIAL STATEMENTS. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION: 61,653. 1 1 1 X 1 X 1 1 0 1 1 122591 122591 0.00630 4776800 4003444 773356 0.03980 4899391 4003444 895947 0.04610 20922 4198 16724 0.00090 20922 4198 16724 0.00090 4920313 4007642 912671 0.04700 0 601070 240000 6239647 6220267 19380 X 1 1 1 1 BURNETT MEDICAL CENTER INC

257 WEST SAINT GEORGE AVENUE GRANTSBURG WI 54840

X X X X BURNETT MEDICAL CENTER INC 1 1 1 150.000000000000 1 200.000000000000 1 X X X X X X 1 1 X X X 1 0 1 X 0 0 2 BURNETT MEDICAL CENTER CLINIC

257 WEST SAINT GEORGE AVENUE GRANTSBURG WI 54840

PROVIDER BASED RURAL HEALTH CLINIC THE CONTINUING CARE CENTER OF BURNETT

MEDICAL CENTER 257 W ST GEORGE AVE GRANSTBURG WI 54840

SKILLED NURSING FACILITY PART I, LINE 7: 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 LESS THE PROVISION FOR BAD DEBTS DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST-TO-CHARGE RATIO IS APPLIED AGAINST HOSPITAL REVENUE AND EXPENSE CATEGORIES TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER IRS COSTING METHODS FOR THE FORM 990. THE COSTING METHODOLOGY USED FOR NURSING HOME SERVICES IS BASED ON MEDICARE COST REPORTING METHODS. 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 $ 601070. PART II: WE ARE CLOSE TO THE COMMUNITIES WE SERVE. IN RESPONSE TO THE GROWING TREND OF ILLEGAL USE OF PRESCRIPTION DRUGS BY THE YOUTH OF OUR NATION AND COMMUNITIES SERVED, BURNETT MEDICAL CENTER CONTINUES TO PARTNER WITH THE BURNETT COUNTY COALITION FOR HEALTHY LIVING IN SPONSORING PRESCRIPTION DRUG DISPOSAL AS PART OF THE NATIONAL TAKE BACK DAY IN BURNETT COUNTY. THE COALITION HOSTS FIVE DROP-OFF SITES THROUGHOUT BURNETT COUNTY: BURNETT COUNTY GOVERNMENT CENTER GRANTSBURG VILLAGE HALL ST. CROIX TRIBAL CLINIC IN HERTEL ST. CROIX TRIBAL HALL IN DANBURY A & H SENIOR CITIZEN'S CENTERTHIS EFFORT CONTINUES TO BRING AWARENESS TO THE NEED FOR PROPER DISPOSAL OF PRESCRIPTION DRUGS, AND INFORMS THE COMMUNITY THAT A PILL DROP BOX IS LOCATED AND ACCESSIBLE FOR THE PROPER DISPOSAL OF DRUGS AT THE BURNETT COUNTY SHERIFF'S DEPARTMENT ENTRANCE OF THE BURNETT COUNTY 24/7. WE CONTINUE TO PROVIDE TIMELY INFORMATION ON THIS INITIATIVE AT OUR WEBSITE, TO HIGHLIGHT THIS GROWING NATIONAL HEALTHCARE CONCERN FOR ADOLESCENTS AND IT IS INTENDED TO ADVANCE THE GENERAL KNOWLEDGE OF THE ISSUE. PART III, LINE 4: ACCOUNTS RECEIVABLE AND CREDIT POLICYTHE COSTING METHOD USED IS BASED ON A COST-TO-CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBTS DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST-TO-CHARGE RATIO IS APPLIED AGAINST THE TOTAL CHARGES THAT ARE WRITTEN OFF DURING THE FISCAL YEAR TO ESTIMATE THE COST OF CHARITY CARE OF PATIENTS THAT HAVE ACCOUNTS THAT ARE DEEMED TO BE BAD DEBTS TO THE MEDICAL CENTER. THE MEDICAL CENTER ALSO PROVIDES DISCOUNTS TO ELIGIBLE UNINSURED OR UNDERINSURED PATIENTS UNDER ITS CHARITABLE CARE POLICY. THESE AMOUNTS ARE INCLUDED IN THE CONTRACTUAL ADJUSTMENTS ON THE FINANCIAL STATEMENTS AND ARE NOT INCLUDED IN THE RATIO AS DESCRIBED ABOVE AND APPROVED BY THE IRS FOR USE ON FORM 990. IF CONSIDERED, THESE ADDITIONAL WRITE-OFF AMOUNTS TO UNINSURED OR UNDERINSURED ACCOUNTS WOULD ALSO INCREASE THE ESTIMATED BAD DEBT EXPENSE ASSOCIATED WITH THESE UNCOLLECTIBLE ACCOUNTS TO THE MEDICAL CENTER. THE COST OF BAD DEBT AMOUNTS IS CONSIDERED A COMMUNITY BENEFIT BECAUSE IT REFLECTS THE COST OF SERVICES PROVIDED TO UNINSURED COMMUNITY MEMBERS AND DEDUCTIBLES OR COINSURANCE AMOUNTS FOR INSURED PATIENTS WHO ARE UNABLE TO PAY FOR A PORTION OF SERVICES.MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH A REDUCTION OF GROSS 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. BALANCES THAT ARE STILL OUTSTANDING AFTER MANAGEMENT HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO ACCOUNTS RECEIVABLE. ACCOUNTS RECEIVABLE ARE RECORDED IN THE ACCOMPANYING BALANCE SHEETS NET OF CONTRACTUAL ADJUSTMENTS AND AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. THE AUDITED FINANCIAL STATEMENTS DO NOT INCLUDE A SEPARATE FOOTNOTE REGARDING BAD DEBT EXPENSE PART III, LINE 8: THE MEDICAL CENTER HAS BEEN DESIGNATED AS A CRITICAL ACCESS HOSPITAL AND THEREFORE DID NOT RECOGNIZE A SHORTFALL FROM THE MEDICARE PROGRAM.THE COST-TO-CHARGE RATIOS USED TO CALCULATE THE COST OF MEDICARE SERVICES WERE TAKEN FROM THE MEDICARE COST REPORT.WHETHER THERE IS A SHORTFALL OR SURPLUS ON SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PEOPLE, WHICH ARE TYPICALLY ELDERLY OR DISABLED MEMBERS OF THE COMMUNITY, 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: PATIENTS RECEIVE OUR COMMUNITY CARE APPLICATION WHEN THEY PRESENT FOR SERVICES. THEY ARE ENCOURAGED TO REVIEW THE APPLICATION AND SUBMIT THE REQUIRED INFORMATION TO APPLY FOR POTENTIAL COVERAGE. IF THEY HAVE QUESTIONS OR NEED HELP WITH THE APPLICATION THEY MAY MEET WITH OUR FINANCIAL COUNSELOR AND/OR OUR BUSINESS OFFICE MANAGER. BURNETT MEDICAL CENTER, INC. PART V, SECTION B, LINE 19D: THE MEDICAL CENTER DETERMINES THE AMOUNT CHARGED TO FAP-ELIGIBLE INDIVIDUALS USING AN INCOME-BASED SLIDING FEE BASED ON FEDERAL POVERTY GUIDELINES. IF AN INDIVIDUAL IS AT 150% OR LESS OF THE FEDERAL POVERTY GUIDELINES, THEN THEY GENERALLY RECEIVE FREE CARE. IF THE INDIVIDUAL EARNS BETWEEN 150% AND 200% OF THE FEDERAL POVERTY GUIDELINES, THEN THEY RECEIVE A DISCOUNTED PRICE BASED ON A SLIDING FEE SCALE. PART VI, LINE 2: WE HAVE USED MARKETING AND DEMOGRAPHIC DATA FOR BOTH OUR PRIMARY AND SECONDARY SERVICE AREAS AS SUPPLIED BY PROPRIETARY SOURCES FROM BOTH THOMSON REUTERS MARKET EXPERT AND THE MINNESOTA HOSPITAL ASSOCIATION. SUCH MARKET-BASED ANALYSIS PROVIDES ESTIMATES AND PROJECTIONS FOR THE MEDICAL NEEDS OF THOSE THAT LIVE WITHIN OUR SERVICE AREA. WE THEN LOOK AT THE AVAILABILITY OF EXISTING HEALTHCARE PROVIDERS AND SERVICES TO DETERMINE WHAT GAPS MAY EXIST, AND HOW WE CAN BEST BE A PART OF ADDRESSING UNMET NEEDS IN PARTNERSHIP WITH BOTH PUBLIC AND PRIVATE PROVIDERS OF HEALTHCARE SERVICES. THE RESULT OF OUR REVIEW AND ANALYSIS BECOMES A FUNDAMENTAL BASIS FOR THE DEVELOPMENT OF GOALS AND OBJECTIVES IN OUR STRATEGIC PLAN. FURTHER, WE ARE IN THE INITIAL STAGES OF CONDUCTING A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) AS REQUIRED UNDER THE PATIENT PROTECTION AND ACCOUNTABLE CARE ACT. WE AWAIT THE RESULTS OF OUR APPLICATION TO THE STATE OF WISCONSIN FOR A $5,000 MINI-GRANT TO ASSIST US IN CONDUCTING THE CHNA. ONCE COMPLETED THE CHNA RESULTS WILL FORM A BASIS FOR HOW TO BEST ADDRESS THESE IDENTIFIED COMMUNITY NEEDS, IN CONJUNCTION WITH MARKETING AND DEMOGRAPHIC DATA. PART VI, LINE 3: PATIENTS ARE TOLD ABOUT OUR COMMUNITY CARE PROGRAM BY OUR FINANCIAL COUNSELOR, REGISTRATION STAFF, PATIENT ACCOUNT REPRESENTATIVES AND BUSINESS OFFICE MANAGER. IN ADDITION, WE HAVE SIGNS POSTED BY BOTH OUR CLINIC AND EMERGENCY ROOM REGISTRATION AREAS INFORMING OUR PATIENTS OF THE COMMUNITY CARE PROGRAM AVAILABLE AT OUR FACILITY. IF THE PATIENT FEELS THEY WILL NEED ASSISTANCE WITH THEIR MEDICAL BILLS, THEY ARE ENCOURAGED TO APPLY FOR THE COMMUNITY CARE PROGRAM WITH ALL THE REQUIRED INFORMATION. PATIENTS ALSO HAVE ACCESS TO THE COMMUNITY CARE APPLICATION INFORMATION ON OUR WEBSITE, FOR EASIER ACCESS FOR OUR PATIENTS. PART VI, LINE 4: BURNETT MEDICAL CENTER (BMC) IS THE ONLY HOSPITAL IN BURNETT COUNTY. WHILE WE SERVE THE ENTIRE COUNTY, AND ADJOINING COUNTIES IN BOTH WISCONSIN AND MINNESOTA, GRANTSBURG, WISCONSIN IS THE PRIMARY SERVICE AREA OF BMC. BASED ON 2012 ESTIMATES, BURNETT COUNTY HAS A POPULATION OF 15,382 WHICH IS ABOUT A .5% REDUCTION FROM THE PREVIOUS ESTIMATES. BURNETT MEDICAL CENTER, A 17 BED FEDERALLY DESIGNATED CRITICAL ACCESS HOSPITAL, IS THE SOLE HOSPITAL IN BURNETT COUNTY. FURTHER, BURNETT COUNTY IS A FEDERALLY DESIGNATED MEDICALLY UNDERSERVED AREA/POPULATION (ID NUMBER 03764), HAVING BEEN SO DESIGNATED ON JUNE 28, 1984. LOCATED IN RURAL NORTHWEST WISCONSIN, BURNETT COUNTY COVERS OVER 820 SQUARE MILES (OR ABOUT 70% THE SIZE OF THE STATE OF RHODE ISLAND), WITH A POPULATION DENSITY OF OR 18.8 PERSONS PER SQUARE MILE (COMPARED TO 105 PER SQUARE MILE IN WISCONSIN). BURNETT COUNTY IS ONE OF THE POORER COUNTIES IN WISCONSIN WITH NEARLY ONE IN FIVE PERSONS (17.8%) LIVING BELOW THE POVERTY LEVEL COMPARED TO A STATE AVERAGE OF 12.0% WITH A MEDIAN INCOME OF $40,686 WHICH IS WELL BELOW THE STATE MEDIAN INCOME OF $51,374. DEMOGRAPHICALLY OUR OVER 65 YEARS OLD POPULATION REPRESENTS NEARLY ONE IN FOUR, OR 23.8% OF THE POPULATION, AND APPROACHING NEARLY DOUBLE THE WISCONSIN STATE AVERAGE OF 13.9%. ACCORDING TO THE US CENSUS, WHILE THE COUNTY POPULATION IS COMPRISED OF PREDOMINATELY WHITE PERSONS AT 91.8%, OUR NEXT LARGEST POPULATION IS AMERICAN INDIAN AT 4.7% (COMPARED TO 1.1% OVERALL FOR THE STATE). IN OUR SECONDARY SERVICE AREAS IN THE NEIGHBORING COUNTIES OF POLK COUNTY IN WISCONSIN AND PINE COUNTY IN MINNESOTA, WE SEE SIMILARITIES. BASED ON CENSUS BUREAU DATA, THEIR COMPARISONS SHOW THEY TOO HAVE FAR FEWER PERSONS PER SQUARE MILE, AND ARE RELATIVELY LOWER THAN THEIR RESPECTIVE STATE AVERAGES FOR MEDIAN HOUSEHOLD INCOME, THE 65+ YEARS OF AGE POPULATION, AND GREATER THAN STATE AVERAGE OF BOTH WHITE PERSONS AND AMERICAN INDIANS.DESPITE OUR RURAL LOCATION IN NORTHWEST WISCONSIN, WE ARE IN A RELATIVELY COMPETITIVE MARKET AS RESIDENTS FROM BOTH OUR PRIMARY AND SECONDARY SERVICE AREAS HAVE ACCESS TO TEN HOSPITALS (IN EITHER WISCONSIN OR MINNESOTA) WITHIN 50 MILES OF THE BURNETT MEDICAL CENTER GEOGRAPHIC LOCATION IN GRANTSBURG, WISCONSIN.FINALLY, WE TAKE OUR ROLE IN PROVIDING A HEALTH CARE SAFETY NET SERIOUSLY FOR ALL, INCLUDING THE UNINSURED, AS EVIDENCED BY OUR 24/7 EMERGENCY DEPARTMENT WHICH PROVIDES EMERGENT, URGENT, AND PRIMARY CARE TO ALL THAT PRESENT TO THE EMERGENCY DEPARTMENT. PART VI, LINE 5: AS A SOLE COMMUNITY RURAL HOSPITAL WE TAKE PRIDE IN BEING CLOSE TO THOSE WE SERVE. WE SHARE WITH THE COMMUNITY VIA PRINT AND RADIO MEDIA, AS WELL AS A GROWING USE OF OUR WEBSITE AND OTHER SOCIAL MEDIA CONTENT OUTLETS KNOWLEDGE OF OUR SERVICES AND SHARING AND PROMOTING OUR MISSION THROUGHOUT THE COMMUNITIES SERVED. WE LEARN DIRECTLY FROM THOSE WE SERVE BY OUR GOVERNING STRUCTURE WHICH IS COMPOSED OF SEVEN UNPAID COMMUNITY VOLUNTEERS FROM THROUGHOUT BURNETT COUNTY, THAT RESIDE IN OUR PRIMARY SERVICE AREA, NONE OF WHICH ARE EMPLOYEES, CONTRACTORS, NOR FAMILY MEMBERS.WE ENJOY THE CONTINUED SUPPORT OF OUR COMMUNITY WITH THE ESTABLISHMENT OF A HEALTHCARE FOUNDATION WHICH PROVIDES PHILANTHROPIC SUPPORT TO FULFILLING THE HOSPITAL'S MISSION.IN ORDER TO ENSURE CONTINUED AND READY ACCESS TO QUALIFIED HEALTHCARE PROVIDERS, WE TAKE PRIDE IN HAVING AN OPEN MEDICAL STAFF MODEL THAT EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PROVIDERS IN OUR COMMUNITY.WHEN WE HAVE SURPLUS FUNDS, THOSE FUNDS ARE USED FOR IMPROVEMENTS IN PATIENT CARE AND QUALITY, AS EVIDENCED BY OUR RECENT RENOVATIONS TO OUR LONG TERM CARE CENTER AND OUR RADIOLOGY DEPARTMENT. WE ALSO HAVE CONTINUED INVESTMENTS AS AN EARLY ADOPTER OF ELECTRONIC MEDICAL RECORDS, SUCCESSFULLY MEETING STAGE ONE MEANINGFUL USE GOALS.ADVOCACY OF THE COMMUNITIES HEALTHCARE NEEDS ARE DONE LOCALLY BY MEMBERS OF THE BOARD SPEAKING WITH LOCAL OFFICIALS ON RELEVANT ISSUES THAT MAY AFFECT THE HOSPITAL. ADDITIONALLY, THE ORGANIZATION'S CEO SERVES AS A MEMBER OF THE WISCONSIN HOSPITAL ASSOCIATION'S BOARD OF DIRECTORS WHICH ADVOCATES FOR INITIATIVES FOR COMMUNITY, STATE AND NATIONAL EFFORTS FOR IMPROVING THE OVERALL HEALTH OF THE POPULATION AND CONTINUED READY ACCESS TO QUALITY HEALTHCARE FOR ALL.MINDFUL OF THE NEED FOR SUPPORT OF VARIOUS METHODS OF INSURANCE, WE ARE PROUD OF OUR PARTICIPATION IN SUCH GOVERNMENTALLY-SPONSORED HEALTHCARE PROGRAMS SUCH AS MEDICARE, MEDICAID, AND TRICARE. REPORTS FILED WITH STATES PART VI, LINE 7 WI X X X 0 0 0 0 0 0 0 0 0 GORDON LEWIS 158109 0 29000 0 490 0 645 0 5729 0 193973 0 0 0 TIMOTHY NOVICK 281045 0 0 0 17176 0 0 0 12676 0 310897 0 0 0 ADEOLA JOLAYEMI 184995 0 25000 0 146 0 0 0 2668 0 212809 0 0 0 VESNA RADIVOJEVIC 172856 0 0 0 157 0 0 0 11947 0 184960 0 0 0 SUPPLEMENTAL INFORMATION PART III GORDON LEWIS AND CHARLES FAUGHT WERE EMPLOYEES OF HEALTHTECH, LLC PROVIDING MANAGEMENT SERVICES TO THE FACILITY THROUGH JANUARY 31, 2011. EFFECTIVE FEBRUARY 1, 2011, GORDON LEWIS AND CHARLES FAUGHT BECAME EMPLOYEES OF THE MEDICAL CENTER. SALARIES AND BENEFITS FOR THE CALENDAR YEAR 2011 REFLECT COMPENSATION FROM BOTH HEALTHTECH, LLC AND BURNETT MEDICAL CENTER, INC. BURNETT COUNTY 396005675 2007-03-23 7000000 TO REFINANCE AND PROVIDE FUNDS FOR BUILDING RENOVATION AND EXPANSION 0 0 0 VILLAGE OF GRANTSBURG 396006277 2007-04-10 5000000 TO PROVIDE FUNDS FOR BUILDING RENOVATION AND EXPANSION 0 0 0 VILLAGE OF SIREN 396008452 2007-04-25 4850000 TO PROVIDE FUNDS FOR BUILDING RENOVATION AND EXPANSION 0 0 0 698413 7000000 140000 5464764 1395236 2008 1 0 1 1 494686 5000000 100000 4900000 2008 0 0 1 1 479845 4850000 97000 4753000 2008 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 EACH PERSON, BUSINESS, CORPORATION OR ORGANIZATION WHO HAS CONTRIBUTED AND PAID ONE HUNDRED DOLLARS OR MORE TO BURNETT MEDICAL CENTER, INC."THE CORPORATION" SHALL BE A LIFETIME MEMBER OF THE CORPORATION. EACH PERSON, BUSINESS, CORPORATION OR ORGANIZATION IS ENTITLED TO HOLD A MAXIMUM OF ONE MEMBERSHIP CERTIFICATE. A HUSBAND AND WIFE, OR TWO OR MORE RELATED PERSONS, MAY HOLD A MEMBERSHIP AS JOINT TENANTS, HOWEVER, ONLY ONE VOTE PER MEMBERSHIP SHALL BE PERMITTED. FORM 990, PART VI, SECTION A, LINE 7A THE DUTIES OF THE MEMBERS OF BURNETT MEDICAL CENTER, INC. "THE CORPORATION" SHALL BE: THE FORMULATION AND DEVELOPMENT OF THE OVERALL PURPOSES; OBJECTIVES AND PHILOSOPHY OF THE CORPORATION; THE ELECTION OF MEMBERS OF THE BOARD OF DIRECTORS OF THE CORPORATION; THE REMOVAL OF MEMBERS OF THE BOARD OF DIRECTORS OF THE CORPORATION; THE CHANGING OF THE NUMBER OF DIRECTORS CONSTITUTING THE BOARD OF DIRECTORS; THE AMENDMENT, RESTATEMENT, OR MODIFICATION OF THE ARTICLES OF INCORPORATION OR BYLAWS OF THE CORPORATION; AND THE APPROVAL OF THE SALE, LEASE, OR OTHER DISPOSITION OF ALL, OR SUBSTANTIALLY ALL OF THE ASSETS AND PROPERTY OF THE CORPORATION OR ITS MERGER WITH ANOTHER CORPORATION. FORM 990, PART VI, SECTION B, LINE 11 THE BOARD OF DIRECTORS FOR BURNETT MEDICAL CENTER, INC. REVIEWED AND APPROVED THE FY 2012 FORM 990 PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C BURNETT MEDICAL CENTER, INC. (BMC) HAS A CONFLICT OF INTEREST POLICY. THE PURPOSE OF THIS POLICY IS TO PROTECT THE INTEREST OF BMC WHEN IT IS CONTEMPLATING ENTERING INTO A TRANSACTION OR ARRANGEMENT THAT MIGHT BENEFIT THE PRIVATE INTEREST OF AN OFFICER OR DIRECTOR OF BMC. IT IS EXPECTED THAT SUCH PERSONS SHALL EXERCISE THE UTMOST GOOD FAITH IN ALL TRANSACTIONS TOUCHING UPON THEIR DUTIES AT BURNETT MEDICAL CENTER AND ITS PROPERTY. ALL MEMBERS OF THE BOARD COMPLETE A DISCLOSURE FORM UPON APPOINTMENT, AND REVIEW AND SIGN IT ANNUALLY THEREAFTER. THIS STATEMENT ESTABLISHES THE DUTY OF AN INTERESTED PARTY TO DISCLOSE THE EXISTENCE OF HIS OR HER FINANCIAL INTEREST AND MUST DISCLOSE ALL MATERIAL FACTS. AFTER ANY SUCH DISCLOSURE, HE/SHE SHALL LEAVE THE GOVERNING BOARD MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON BY THE REMAINING BOARD MEMBERS. IF THE BOARD HAS REASONABLE CAUSE TO BELIEVE THAT A MEMBER HAS FAILED TO DISCLOSE ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, IT SHALL INFORM THE MEMBER OF THE BASIS OF SUCH BELIEF AND AFFORD THE MEMBER AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. IF MEMBERS FAIL TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, BMC SHALL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION. FORM 990, PART VI, SECTION B, LINE 15 BURNETT MEDICAL CENTER INC.'S EXECUTIVE COMPENSATION POLICY IS DESIGNED WITH THE GOAL OF PROVIDING REMUNERATION THAT IS FAIR, REASONABLE AND COMPETITIVE. THE HOSPITAL BOARD MAY ESTABLISH A COMPENSATION COMMITTEE OR MAY ACT AS A COMMITTEE OF THE WHOLE IN EXECUTIVE SESSION. THE COMMITTEE OVERSEES THE TOTAL COMPENSATION PACKAGES TO ENSURE THAT THEY ARE COMPETITIVE WITH OTHER HEALTHCARE ORGANIZATIONS, REFLECT JOB RESPONSIBILITIES AND REQUIREMENTS AND ARE FAIR, EQUITABLE AND CONSISTENTLY MANAGED. THE COMMITTEE MEETS AS OFTEN AS IT DEEMS APPROPRIATE TO CARRY OUT ITS RESPONSIBILITIES. IN GENERAL, BMC POSITIONS TOTAL EXECUTIVE COMPENSATION AT THE MEDIAN OF THE MARKET. THE BOARD OF DIRECTORS USES CONTEMPORANEOUS DATA INCLUDING EXECUTIVE COMPENSATION DATA FROM THE WISCONSIN HOSPITAL ASSOCIATION AS A GUIDE WHEN APPROVING THE COMPENSATION OF THE ADMINISTRATOR AND CHIEF FINANCIAL OFFICER. THE POLICY IS MEANT TO BE FLEXIBLE SO THAT COMPENSATION CAN BE ABOVE OR BELOW THE MEDIAN BASED ON EXPERIENCE, PERFORMANCE, SIZE AND COMPLEXITY OF ORGANIZATION, AND BUSINESS NEED TO ATTRACT AND RETAIN EXECUTIVE TALENT. FORM 990, PART VI, SECTION C, LINE 19 BURNETT MEDICAL CENTER, INC. MAKES IT FINANCIAL STATEMENTS AND GOVERNING DOCUMENTS AVAILABLE TO THE PUBLIC ON A PER REQUEST BASIS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -8,889. CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION: 61,653. TOTAL TO FORM 990, PART XI, LINE 5: 52,764. OVERSIGHT OF THE AUDIT FORM 990, PART XII, LINE 2C BURNETT MEDICAL CENTER, INC. DOES NOT HAVE A SPECIFIC COMMITTEE WHICH ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT. THE ENTIRE BOARD OF DIRECTORS IS RESPONSIBLE FOR THE SELECTION OF THE INDEPENDENT ACCOUNTANT. THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR.