2013-08-14T15:53:00-05:00 2012-09-30 450250958 EIDE BAILLY LLP 200 EAST 10TH ST PO BOX 5125 SIOUX FALLS SD 571175125 990 2011-10-01 460255944 Mobridge Regional Hospital MOBR 6058453692 1401 10th Ave W Mobridge SD 57601 Angelia Svihovec 6058453692 2013-08-14 1 Laurie Hanson P00851848 6053391999 2013-08-14 2011 2016-02-24 21:20:13Z Angelia Svihovec 1401 10th Ave W Mobridge SD 57601 18932911 0 X www.mobridgehospital.org X 1959 SD Providing healthcare to people throughout the region. 12 10 180 175 0 0 190133 919867 14204803 15865149 57910 48647 86418 88669 14539264 16922332 0 0 0 0 7780487 8818289 0 0 0 6481946 6862465 14262433 15680754 276831 1241578 16958515 17807982 6783040 6390929 10175475 11417053 The mission of Mobridge Regional Hospital is to provide high quality healthcare services in a compassionate and professional manner for people throughout the region. 0 0 13914323 15865149 Mobridge Regional Hospital (MRH) provides healthcare services to persons throughout the region. During the fiscal year ended September 30, 2012, the hospital had: 1,734 Patient Days 1,320 Acute Care Days32,223 Outpatient Visits 4,983 Assisted Living Days (Prairie Sunset Village) 13914323 1 0 0 0 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 19 0 1 180 1 0 0 0 0 0 0 0 0 0 0 X 12 10 0 1 0 0 1 1 0 1 0 0 0 0 1 1 1 1 1 1 1 0 X Renae Tisdall 6058458164 PO Box 580 Mobridge SD 57601 Dennis Schnabel 1.00 X X 0 0 0 Delphine Steuck 1.00 X X 0 0 0 Bill Bachmeier 1.00 X X 0 0 0 Heidi Roshau 1.00 X X 0 0 0 Jake Kraft 1.00 X 0 0 0 Wally Schott 1.00 X 0 0 0 Donald Paulson 1.00 X 0 0 0 Dr Leonard Linde 1.00 X 0 0 0 Barb Gross 1.00 X 0 0 0 Dr Tom Swanson 1.00 X 0 0 0 Dr Travis Henderson 40.00 X 250166 0 25971 Dr Robert Marciano 40.00 X 257826 0 18581 Dr Bela Csaki 40.00 X 284429 0 18822 Dr Colette Reule 40.00 X 272759 0 18134 Dr Kenric Malmberg 40.00 X 237759 0 23281 James Curran 40.00 X 188473 0 23236 Debbie Smith 40.00 X 196648 0 19373 Angelia Svihovec 40.00 X 0 0 0 Renae Tisdall 40.00 X 71688 0 25280 1759748 0 172678 11 0 1 0 Johnson Controls PO Box 730068 Dallas TX 75373 Construction 288805 St Alexius Medical Center 900 East Broadway Bismarck ND 58506 IT services, CEO salary, supplies, etc 235933 Mondak Imaging Services 11 South 7th St 241 Miles City MT 59301 MRI services 141613 Northern Plains Lab PO Box 2036 Bismarck ND 58502 Outsource laboratory services 113453 4 688900 230967 919867 Patient Service Rev 622110 15221160 15221160 Assisted Living Rev 623110 477182 477182 Ancillary Charges 900099 125689 125689 Chng in Fdtn Int 900099 41118 41118 15865149 45647 45647 88669 0 88669 88669 88669 2010579 3000 2010579 0 0 3000 3000 3000 16922332 15865149 0 137316 653317 554126 99191 6572070 5926268 645802 222931 197680 25251 912266 912266 457705 403510 54195 209703 209703 2054 2054 41650 41650 455886 454098 1788 63692 5199 58493 232626 85763 146863 48355 20878 27477 295498 291409 4089 35044 35044 51178 46068 5110 247336 247336 1101930 1101930 152193 66335 85858 MEDICAL SUPPLIES 1872928 1872928 BAD DEBT 1452038 1452038 EQUIPMENT AND MAINTENAN 491104 429419 61685 DUES AND SUBSCRIPTIONS 64788 25584 39204 44462 33780 10682 15680754 13914323 1766431 0 5402123 4831323 2144039 2644276 68513 30296 492187 492886 119033 140917 21301644 12993025 7473750 8308619 556364 658277 702506 701388 16958515 17807982 1586309 1391633 19000 19000 4755000 4450000 279795 327784 142936 202512 6783040 6390929 X 9682213 10812795 493262 604258 10175475 11417053 16958515 17807982 1241578 0 X 0 1 1 X 0 X 95575 95575 10527105 6502059 4025046 8786616 6209846 2576770 1892348 281120 1611228 8308619 Premium on Bonds Payable 12395 Deferred Compensation Plan Payable 190117 202512 16922332 15680754 1241578 1241578 15470294 0 15470294 1452038 1452038 16922332 14228716 0 14228716 1452038 1452038 15680754 Description of Uncertain Tax Positions Under FIN 48: Part X: The Organization believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the financial statements. The Organization would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. 1 1 X 0 1 X 1 1 1 0 1 1 113000 113000 0.00790 2893016 1924146 968870 0.06810 3006016 1924146 1081870 0.07600 1130253 772413 357840 0.02510 1130253 772413 357840 0.02510 4136269 2696559 1439710 0.10110 0 1452038 1234232 4665510 4599082 66428 X 1 0 1 1 Mobridge Regional Hospital

1401 10th Avenue W Mobridge SD 57601

X X X X Mobridge Regional Hospital 1 0 1 0 1 300.000000000000 1 X X 1 1 X X X X X 1 0 1 X 1 0 4 Prairie Sunset Village

1320 W Grand Xing Mobridge SD 57601

Assisted Living & Senior Housing Mobridge Medical Clinic

1309 10th Ave W Mobridge SD 57601

Provider Based Rural Health Clinic West River Health Clinic

103 1st Avenue E McLaughlin SD 57642

Provider Based Rural Health Clinic West Dakota Health Clinic

906 Main Timber Lake SD 57656

Provider Based Rural Health Clinic Part I, Line 3c: MRH does not provide free care. MRH offers financial assistance discounts of up to 85% based on FPG. Part I, Line 6a: MRH's community benefit information is included in the hospital's annual report, which is mailed out to members and is available in the lobby at the hospital and clinics. Part I, Line 7: Charity care expense was converted to cost on line 7a based on an overall cost-to-charge ratio addressing all patient segments. Line 7b was determined using the Medicaid PS&R report and the general ledger accounting system. Line 7g was determined using the Medicare cost report for fiscal year ending 9/30/12. Part I, L7 Col(f): Bad debt expense of $1,452,038 was subtracted from total operating expense. Part III, Line 4: a) When a payment is received or a discount given on a bad debt account it offsets the current fiscal year bad debt expense through a recovery of bad debt account. b) Bad debt expense attributable to charity care is estimated based on income levels. A large portion of MRH charges are generated by the Native American population and those below the poverty level. Statistics prove that most of the mentioned patients qualify for charity care. After review, MRH estimates approximately 85% of bad debt at cost is attributable to persons who would qualify for charity care. c) Footnote From Financial Statement: Patient and resident accounts receivable are reduced by an allowance for doubtful accounts. In evaluating the collectability of accounts receivable, the Organization 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. Management regularly reviews data about these major payor sources of revenue in evaluating thesufficiency of the allowance for doubtful accounts. For receivables associated with services provided to patients who have third party coverage, the Organization analyzes contractually due amounts and provides an allowance for doubtful accounts and a provision for bad debts, if necessary. 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 Organization 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 and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowance for doubtful accounts. Part III, Line 8: Medicare Allowable Cost of Care was calculated from the Medicare Cost Report for fiscal year ending 9/30/12. Mobridge Regional Hospital Part V, Section B, Line 9: MRH does not provide free care. MRH offers financial assistance discounts of up to 85% based on FPG. Mobridge Regional Hospital Part V, Section B, Line 13g: Lines 13b, c, d, f and g: A summary of the policy is provided. A summary is also included with discharge materials. Mobridge Regional Hospital Part V, Section B, Line 19d: The maximum amount charged to a patient under the financial assistance policy for emergency and medically necessary care is 50% of the gross charges. This is based on the lowest discount under the charity care policy of 50%. The hospital will review the proposed methods to determine amounts generally billed to ensure its discount under the financial assistance policy meets the requirements of 501(r). Mobridge Regional Hospital Part V, Section B, Line 20: The hospital provides a reduction to gross charges under the following conditions: patients indicate they have family income of no more than 300% of FPG, are uninsured or underinsured, and complete the required paperwork to be eligible for financial assistance.The hospital has not determined the amount generally billed under the various proposed methods of calculation. Therefore, it is possible a patient under the financial assistance policy could have paid more than the amount generally billed. The hospital will review the various methods to determine amounts generally billed to ensure it is in compliance with Section 501(r). Part VI, Line 2: Mobridge Regional Hospital (MRH) is committed to providing high quality healthcare services to all people throughout the region. The facility provides family medicine, internal medicine, OB, ICU, ALS, ambulance service, emergency care, and surgical services to all people who are in need of those services. MRH currently is working in collaboration with Walworth County and the State of South Dakota to provide Community Health Services, including family planning services, adult health, and child immunizations. MRH's management strives to listen to the community needs. If new healthcare needs arise, administration will complete an analysis of cost/benefit for the new service to be offered. MRH's administration believes in being out in the public at events to answer questions that may surface about the facility. Part VI, Line 3: MRH posts its charity care policy, or a summary thereof, and financial assistance contact information in the admissions areas and clinic areas in which eligible patients are likely to be present. The facility provides a copy of the policy, or a summary thereof, and financial assistance contact information to patients with discharge materials. The Patients Account Manager discusses with the patient the availability of various government benefits, such as Medicaid or state programs, and assists the patient with qualification for such programs, where applicable.MRH's charity care program is available to both new and established patients. The charity care policy covers all medically necessary services provided by the institution that are ordered by physicians.MRH's charity care program is available to all patients who indicate an inability to pay and meet the criteria as established by the hospital for all or a portion of their outstanding hospital bill. Part VI, Line 4: MRH is located in a small rural community in Walworth County, South Dakota, known as Mobridge. According to the 2010 Census, Mobridge has a population of 3,465 people racially comprised of mainly Caucasian (75.67%) and Native Americans (20.46%). The community borders the Standing Rock Reservation and the Cheyenne River Reservation which accounts for the larger Native American population and relations with Indian Health Services. The median household income of Mobridge is $37,417, and the median family income is $52,316. Roughly 17.6% of the population is below the poverty line. The facility owns and operates clinics in Mobridge, McLaughlin and Timber Lake. The facility serves patients from a six county area (Walworth, Ziebach, Corson, Dewey, Campbell and Potter) and is approximately one hundred miles from another hospital with a higher level of care offered. According to the 2010 Census, Ziebach county is the poorest county in America, and 62% of people living in this county are under federal poverty guidelines. Corson County ranked 9th of the poorest counties in America. Part VI, Line 5: The Mobridge Regional Hospital is committed to the patients we serve, regardless of race, color, religion, sex, disability, or ability to pay. The organization's charity care write-offs have continued to trend up over the past few years, and we continue to focus budget efforts to continue this trend. MRH is 100 miles from another healthcare facility with a higher level of care and participates in the North Dakota and South Dakota trauma systems with level III and level IV certifications, respectively. MRH continues a broad level of board involvement for Corson, Dewey, and Walworth Counties to monitor community needs in those areas. MRH continues to be a popular place for medical students to complete clinical rotations, and we continue to offer a wide variety of certification classes to nurses and the members of the community including EMT-B, PALS, ACLS, TNCC, ALSO, NALS, EMT-I, and CPR. MRH also has developed a worksite wellness program within the organization and has goals to work with other businesses in the community to promote overall healthy lifestyles.MRH also provides various health screenings available to the community and surrounding communities throughout the year. The health screenings include free cholesterol checks, BMI, blood pressure and waist/hip ratios. These preventative health screenings promote the general health of the community.The hospital has a Board of Directors comprised of volunteers who reside in the service area. Medical staff privileges are extended to all qualified physicians in the area. All qualified physicians who show an interest must go through a credential review and board approval. Surplus funds, if available, are reinvested in the facilities to improve patient care. X X 0 0 0 0 0 0 0 1 0 Dr Travis Henderson 201650 0 43190 0 5326 0 9800 0 16545 0 276511 0 0 0 Dr Robert Marciano 208818 0 44536 0 4472 0 9800 0 9148 0 276774 0 0 0 Dr Bela Csaki 275288 0 0 0 9141 0 9800 0 9262 0 303491 0 0 0 Dr Colette Reule 215875 0 53399 0 3485 0 9800 0 8651 0 291210 0 0 0 Dr Kenric Malmberg 182250 0 50339 0 5170 0 9311 0 14292 0 261362 0 0 0 James Curran 185233 0 0 0 3240 0 7668 0 15752 0 211893 0 0 0 Debbie Smith 188408 0 0 0 8240 0 7668 0 12072 0 216388 0 0 0 Part I, Line 7 The physicians are paid based on production. City of Mobridge South Dakota 466000320 607429BA4 2007-05-08 5773898 Refinance bonds issued 1997 used for construction; purchase CT, Clinic & EMR 0 0 0 1305000 5773898 267790 88005 1000000 4416499 2008 0 1 1 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0 Form 990, Part VI, Section A, line 3 MRH currently has a management agreement with St. Alexius Medical Center in Bismarck, ND. The agreement provides the CEO, Angelia K. Svihovec, and information technology support at a cost to MRH. The original management agreement date was January 1, 2000. Angelia Svihovec, CEO, received W-2 compensation of $152,413 during the calendar year ended 12/31/11. Form 990, Part VI, Section A, line 6 There is only one class of member; all members have one vote (same voting rights). Form 990, Part VI, Section A, line 7a The nominating committee nominates candidates for election. The members vote on candidates at the annual meeting. Form 990, Part VI, Section A, line 8b There is no committee with the authority to act on behalf of the governing body. Form 990, Part VI, Section B, line 11 The CEO, CFO, and Finance Committee will review the Form 990 prior to filing with the IRS. Form 990, Part VI, Section B, line 12c The conflict of interest policy covers the entire Board of Directors. If a conflict should arise, it would first go to the CEO for evaluation, then to the Board of Directors for final evaluation. The Board of Directors is responsible for making the final decision in determining if a conflict exists. If a conflict is found, the person(s) involved would be required to abstain from discussions and voting on the item causing the conflict. Form 990, Part VI, Section B, line 15 The Finance Committee determines and approves the physician contracts, including compensation. The CEO's salary is determined using a salary survey and discussions with the management company. The Finance Committee approves the salary of the CEO annually. The Board of Directors approves the Finance Committee minutes, which include discussions regarding the CEO's salary. Salaries for other Officers or Key Employees are determined by the CEO through the use of salary survey information from SDAHO and employee service and experience files. Salary increases were implemented in September 2012. Form 990, Part VI, Section C, line 19 Documents are made available upon request.