2012-10-10T12:26:21-05:00 2011-12-31 390758449 WIPFLI LLP 3703 OAKWOOD HILLS PARKWAY EAU CLAIRE WI 54701 990 2011-01-01 390806828 MEMORIAL HOSPITAL INC MEMO 7157433101 216 SUNSET PLACE NEILLSVILLE WI 54456 KELLY MOEN 7157433101 2012-10-09 1 HOLLY POKRANDT CPA P00449155 7158323407 2012-10-09 2011 2016-02-24 21:20:13Z KELLY MOEN 216 SUNSET PLACE NEILLSVILLE WI 54456 23271900 0 X WWW.MEMORIALMEDCENTER.ORG X 1954 WI MEMORIAL HOSPITAL'S MISSION IS TO PROVIDE THE COMMUNITIES WE SERVE THE BEST EXPERIENCE IN HEALTH CARE, EDUCATION, AND PREVENTION SUPPORTED BY OUR PILLARS OF PEOPLE, SERVICE, QUALITY, AND SAFETY, FINANCE, COMMUNITY, AND GROWTH...ONE PATIENT AT A TIME. MEMORIAL HOSPITAL, INC. PROVIDES SERVICES THROUGH THE 25-BED CRITICAL ACCESS HOSPITAL, HOME HEALTH AGENCY, ASSISTED LIVING, AS WELL AS 3 RURAL HEALTH CLINICS IN NEILLSVILLE, LOYAL, AND GREENWOOD. TO FULFILL COMMUNITY NEEDS, MEMORIAL HOSPITAL, INC. FACILITATES EDUCATIONAL SEMINARS AND SUPPORT GROUPS LED BY MEDICAL AND PROFESSIONAL STAFF AT GREATLY REDUCED-RATES; PROVIDES FREE HEALTH SCREENINGS AT GIVEN TIMES THROUGHOUT THE YEAR; STAFF BOOTHS AT COMMUNITY EVENTS; SERVES AS AN EDUCATION SITE FOR STUDENTS IN HIGH SCHOOL, TECHNICAL COLLEGE, AND UNIVERSITIES; AS WELL AS OTHER NEEDS AS DETERMINED. MEMORIAL HOSPITAL, INC. ALSO ADMINISTERS A CHARITY CARE PROGRAM HELPING TO ENSURE AFFORDABLE ACCESS TO HEALTHCARE. 11 9 287 78 443461 -221497 68077 104597 22288934 22637768 629306 59427 380707 458405 23367024 23260197 0 0 0 0 14673153 14159170 0 0 0 7143353 7403465 21816506 21562635 1550518 1697562 16588627 17909273 4241300 3884093 12347327 14025180 X TO PROVIDE THE COMMUNITIES WE SERVE THE BEST EXPERIENCE IN HEALTH CARE, EDUCATION, AND PREVENTION, SUPPORTED BY OUR PILLARS OF PEOPLE, SERVICE, QUALITY AND SAFETY, FINANCE, COMMUNITY, AND GROWTH...ONE PATIENT AT A TIME. 0 0 13057701 18446374 HOSPITAL INPATIENT SERVICES IN 2011 INCLUDED 913 ACUTE CARE PATIENT DAYS, 191 OBSERVATION DAYS, AND 861 SWING BED PATIENT DAYS.EMERGENCY ROOM VISITS TOTALLED 3,919 AND SURGERIES AND PROCEDURES TOTALLED 1,056 IN 2011.OTHER HOSPITAL SERVICES PROVIDED IN 2011 INCLUDED BUT WERE NOT LIMITED TO ATHLETIC TRAINING, DIETARY, OBSTETRICS, PAIN MANAGEMENT, PHARMACY, PHYSICAL THERAPY, RADIOLOGY, LABORATORY, CARDIAC REHABILITATION, SPEECH THERAPY, RESPIRATORY THERAPY, OCCUPATIONAL THERAPY, SOCIAL SERVICES, DIABETIC EDUCATION, AND HOME HEALTH SERVICES. 4582789 3683458 A TOTAL OF 24,098 CLINIC VISITS OCCURRED IN 2011 AT THE THREE CLINICS LOCATED IN NEILLSVILLE, LOYAL, AND GREENWOOD. 738747 347020 THE ASSISTED LIVING FACILITY IS AN ALTERNATIVE FOR SENIORS WHO CAN NO LONGER LIVE SAFELY IN THEIR OWN HOME, YET DO NOT NEED 24-HOUR MEDICAL SUPERVISION. SUNSET GARDENS IS A HOUSING AND HEALTH CARE ALTERNATIVE, COMBINING INDEPENDENCE WITH PERSONAL CARE, IN A WARM, DIGNIFIED, HOME-LIKE ATMOSPHERE. SUNSET GARDENS HAS 11 PRIVATE ROOMS AND 2 DOUBLE ROOMS, FOR A COUPLE OR SIBLINGS. MEALS, SNACKS, HOUSEKEEPING, LAUNDRY, CABLE TELEVISION, AND MAINTENANCE SERVICES ARE PROVIDED. SOCIAL AND RECREATIONAL PROGRAMS AND A CHAPEL ARE ALSO PROVIDED. HEALTH CARE SERVICES INCLUDE A REGISTERED NURSE ON-SITE OR ON-CALL 24 HOURS PER DAY, MEDICATION MANAGEMENT, PERSONAL CARE SERVICES PROVIDED BY CERTIFIED NURSING ASSISTANTS (SUCH AS ASSISTANCE WITH BATHING, DRESSING, AND GROOMING). THE ASSISTED LIVING PROVIDED 3,550 RESIDENT DAYS. 18379237 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 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 16 0 1 287 1 1 1 0 0 0 0 0 0 0 0 0 X 11 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 1 1 1 0 WI X KELLY MOEN MEMORIAL HOSPITAL INC 7157433101 216 SUNSET PLACE NEILLSVILLE WI 54456 ALLAN HOESLY 1.00 X X 300 0 0 DR JAMES STANGA 53.00 X 315911 0 23567 JEANETTE STEINER 1.00 X 225 0 0 RICK SZYMANSKI 1.00 X X 300 0 0 ROBERT BARTH 1.00 X X 300 0 0 WENDY SIGURDSON 1.00 X 200 0 0 TREVOR WUETHRICH 1.00 X 150 0 0 KEVIN GRAPP 1.00 X 100 0 0 TIM RUETH 1.00 X 0 0 0 DOROTHY WELSH 1.00 X 225 0 0 DR KENNETH WEIMER 36.00 X 207014 0 26028 DR TIM MEYER 35.00 X 363067 0 11281 SCOTT POLENZ 58.00 X 190737 0 25067 KELLY MOEN 47.00 X 102778 0 22222 SHARON LOANEY-BERGSHOLM 46.00 X 98991 0 19969 DR GRACE CRUZ-APOLINARIO 36.00 X 467983 0 23567 DRDAVID PAUSTIAN 38.00 X 833061 0 18829 DR AMY COULTHARD 46.00 X 207389 0 9821 DR CAROLYN HARDESTY 37.00 X 212935 0 18828 DR RANDE SHORT 60.00 X 163657 0 5348 3165323 0 204527 14 0 1 0 CMDI PO BOX 158 MILACA MN 56353 CT SERVICES 255100 WI ANESTHESIA SERVICE LLC W5844 ROLLING HILLS DRIVE NEILLSVILLE WI 54456 CRNA SERVICES 234512 THOMAS R SILBERNAGEL W5844 ROLLING HILLS DRIVE NEILLSVILLE WI 54456 CRNA SERVICES 220875 SHARED MEDICAL SERVICES INC PO BOX 330 COTTAGE GROVE WI 53527 MRI SERVICES 114945 4 51296 53301 104597 HOSPITAL REVENUE 621990 18446374 18446374 CLINIC REVENUE 621110 3683458 3683458 ASSISTED LIVING REVENU 623000 347020 347020 160916 160916 22637768 59300 59300 14944 0 14944 14944 14944 11830 11703 127 127 127 DIET,MAINT,HSKG,LNDRY 722230 443461 443461 443461 23260197 22476852 443461 235287 1408432 1065828 342604 9755296 8258245 1497051 313444 265343 48101 2008165 1703829 304336 673833 564391 109442 41509 41509 59800 59800 1519418 1517985 1433 83206 2790 80416 756581 537591 218990 456108 360964 95144 7616 7616 107636 92676 14960 639742 506292 133450 248436 71211 177225 MEDICAL SUPPLIES 1603852 1603852 BAD DEBT 1292507 1292507 REPAIRS & MAINTENANCE 308749 308749 ADMIN HOSPITAL TAX EXPE 132960 132960 145345 86408 58937 21562635 18379237 3183398 0 4469532 5142924 2350895 2361608 2053995 2010074 382552 387350 191113 242491 15245657 8912702 5688039 6332955 1452501 1431871 16588627 17909273 2107087 2080208 547 4117 1210000 935000 296737 116587 626929 748181 4241300 3884093 X 12347327 14025180 12347327 14025180 16588627 17909273 X 1697562 -19709 X X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3524 3524 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: A PORTION OF THE ANNUAL DUES ($940) PAID TO THE WISCONSIN HOSPITAL ASSOCIATION WAS USED FOR LOBBYING EXPENDITURES AND A PORTION OF ANNUAL DUES PAID TO THE RURAL WISCONSIN HEALTH COOPERATIVE ($2,584) WAS USED FOR LOBBYING EXPENDITURES. THE DUES PAID TO THESE ORGANIZATIONS ARE PRIMARILY FOR EDUCATIONAL MATERIALS, STAFF TRAINING, AND ADMINISTRATIVE SERVICES, BUT THE AMOUNTS IDENTIFIED ABOVE REPRESENT THE PORTION OF THESE DUES USED FOR LOBBYING ACTIVITIES. 20673 20673 10783940 6210081 4573859 3244260 2495361 748899 1196784 207260 989524 6332955 UNAMORTIZED BOND ISSUE COSTS 17039 INVESTMENT IN CENTRAL MN DIAGNOSTIC, INC. 379054 DEFERRED COMPENSATION PLAN ASSETS 752778 AMOUNTS RECEIVABLE FROM THIRD-PARTY REIUMBURSEMENT PROGRAMS 283000 1431871 DEFERRED COMPENSATION LIABILITY 748181 748181 23260197 21562635 1697562 -19709 -19709 1677853 23240488 -19709 -19709 23260197 0 23260197 21562635 0 21562635 0 21562635 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL IS A NONPROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE "CODE") AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE HOSPITAL IS ALSO EXEMPT FROM STATE INCOME TAXES ON RELATED INCOME. IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE ORGANIZATION DETERMINES 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 TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE LIKELY THAN NOT RECOGNITION THRESHOLD, THE BENEFIT OF THE TAX POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE HOSPITAL IS ALSO ENGAGED, TO A LIMITED EXTENT, IN ACTIVITIES THAT THE INTERNAL REVENUE SERVICE CONSIDERS UNRELATED TO THE HOSPITAL'S EXEMPT PURPOSE AND, THEREFORE, TAXABLE. THESE ACTIVITIES, HOWEVER, ANNUALLY RESULT IN NET OPERATING LOSSES FOR INCOME TAX PURPOSES. THE HOSPITAL DOES NOT PRESENTLY ANTICIPATE THAT A TAX BENEFIT FROM THESE NET OPERATING LOSSES WILL BE REALIZED IN THE FUTURE. ACCORDINGLY, ANY POTENTIAL DEFERRED TAX ASSET RESULTING FROM THE AVAILABILITY OF NET OPERATING LOSS CARRYFORWARDS IS OFFSET BY A CALCULATION ALLOWANCE OF EQUAL AMOUNT. NO DEFERRED TAX ASSETS AND LIABILITIES HAVE BEEN RECOGNIZED SINCE NO OTHER DIFFERENCES EXIST BETWEEN THE FINANCIAL AND TAX BASIS OF REPORTING THE HOSPITAL'S ASSETS AND LIABILITIES. THE ORGANIZATION'S POLICY IS TO RECOGNIZE INTEREST AND ANY PENALTIES RELATED TO INCOME TAX MATTERS IN INCOME TAX WHEN INCURRED. AS OF AND FOR THE YEARS ENDED DECEMBER 31, 2011 AND 2010, THERE WAS NO INCOME TAX EXPENSE, TAX PENALTIES, OR INTERST RELATED TO TAX PENALTIES RECORDED BY THE ORGANIZATION IN THE FINANCIAL STATEMENTS. IN ADDITION, THE ORGANIZATION RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2011 AND 2010. FEDERAL RETURNS FOR THE YEARS 2008 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. 1 1 1 X 49.000000000000 1 X 1 1 0 1 1 82695 82695 0.00410 4642070 3222959 1419111 0.07000 4724765 3222959 1501806 0.07410 67775 5630 62145 0.00310 195725 195725 0.00970 3763589 1033110 2730479 0.13470 24989 24989 0.00120 4052078 1038740 3013338 0.14870 8776843 4261699 4515144 0.22280 867 867 0.00000 428 428 0.00000 4000 4000 0.00020 18114 18114 0.00090 23409 23409 0.00110 0 688139 275250 4288331 4333577 -45246 X 1 1 1 1 MEMORIAL HOSPITAL INC

216 SUNSET PLACE NEILLSVILLE WI 54456

X X X X MEMORIAL HOSPITAL INC 1 1 1 49.000000000000 1 300.000000000000 1 X X X X X 1 1 X X X 1 0 1 X 0 0 5 MEMORIAL MEDICAL CENTER

216 SUNSET PLACE NEILLSVILLE WI 54456

PROVIDER BASED RURAL HEALTH CLINIC SUNSET GARDENS

216 SUNSET PLACE NEILLSVILLE WI 54456

ASSISTED LIVING FACILITY LOYAL CLINIC - MEMORIAL MEDICAL CENTER

502 EAST ELM STREET LOYAL WI 54446

PROVIDER BASED RURAL HEALTH CLINIC MEMORIAL MEDICAL CENTER

216 SUNSET PLACE NEILLSVILLE WI 54456

HOME HEALTH AGENCY GREENWOOD FAMILY MEDICAL CENTER

201 SOUTH MAIN GREENWOOD WI 54437

PROVIDER BASED RURAL HEALTH CLINIC PART I, LINE 3C: MEMORIAL HOSPITAL GENERALLY USES 49% OF FEDERAL POVERTY GUIDELINES FOR OFFERING FREE CARE AND A SLIDING SCALE GOING UP TO 300% OFFERING REDUCED CHARGES FOR CARE. IT SHOULD ALSO BE NOTED THAT MEMORIAL HOSPITAL, AS A PART OF ITS COMMUNITY CARE POLICY, WILL ALSO CONSIDER AN ADMINISTRATIVE REVIEW OF OTHER OUTSTANDING BALANCES OF AN INDIVIDUAL. WE WILL DETERMINE ON AN INDIVIDUAL BASIS IF ADDITIONAL DISCOUNTS CAN BE PROVIDED TO PATIENTS. A PATIENT MAY HAVE A SIGNIFICANT OR LONG TERM NEED OF MEDICAL BILLS THAT MAY REQUIRE ADDITIONAL COMMUNITY SUPPORT TO HELP A PATIENT THROUGH A DIFFICULT TIME. PART I, LINE 7: THE CALCULATED PERCENT OF TOTAL EXPENSES EXCLUDES BAD DEBT EXPENSE. 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 MINUS THE PROVISION FOR BAD DEBTS AND IT IS DIVIDED BY GROSS PATIENT SERVICE REVENUES. THIS COST TO CHARGE RATIO WAS USED TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER THE IRS SUGGESTED COSTING METHODS FOR THE FORM 990. PART I, LINE 7G: THE COST OF SUBSIDIZED HEALTH SERVICES IS BASED ON COST ALLOCATIONS FROM THE MEDICARE COST REPORT. ALLOWABLE COSTS ARE ASSIGNED DIRECTLY TO DEPARTMENTS THROUGHOUT THE YEAR AND THEN THE COST REPORT USES THE ALLOCATION METHODOLOGY TO ASSIGN ALL OTHER COSTS TO CALCULATE SERVICE LINE COSTS. SUBSIDIZED HEALTH SERVICES INCLUDE THE OPERATION OF THREE FAMILY PRACTICE CLINICS. IT IS THE GOAL OF MEMORIAL HOSPITAL, INC. TO PROVIDE THESE SERVICES TO THE COMMUNITY REGARDLESS OF A PATIENT'S ABILITY TO PAY. 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 $ 1292507. PART II: COMMUNITY BUILDING ACTIVITIES PROMOTES THE HEALTH OF THE COMMUNITY THAT OUR HOSPITAL SERVES. THROUGH COLLABORATION WITH LOCAL ORGANIZATIONS, WE PROVIDE INFORMATION TO THE COMMUNITY REGARDING VARIOUS ISSUES THAT AFFECT HEALTH SUCH AS BABYSITTING CLASSES, ELDER COMMUNITY PROGRAMS, SERVING ON PUBLIC HEALTH BOARDS, WORKING WITH DISASTER PREPAREDNESS, CPR CLASSES, DIABETIC SUPPORT GROUPS, PRESCRIPTION ASSISTANCE, STRESS MANAGEMENT, PREVENTATIVE SERVICES, AND OTHERS. PART III, LINE 4: BAD DEBTS ARE RECORDED IN A CONSISTENT MANNER WITH THE ORGANIZATION'S COLLECTION POLICIES. THE TOTAL IS RECORDED IN GROSS CHARGES AND THEN THE COST TO CHARGE RATIO IS APPLIED TO CALCULATE THE COST OF BAD DEBTS.THERE ARE A NUMBER OF PATIENTS THAT TRULY DO NOT HAVE THE ABILITY TO PAY BUT DO NOT FILL OUT THE PAPERWORK TO RECEIVE CHARITY CARE. THE FACILITY DOES NOT HAVE A PRESUMPTIVE ELIGIBILITY PROGRAM AT THIS TIME TO IDENTIFY THOSE INDIVIDUALS. OUR FACILITY CONTINUES TO PROVIDE HEALTHCARE TO THOSE IN NEED REGARDLESS OF THEIR ABILITY TO PAY. FOR THE BAD DEBTS RECORDED THERE WERE SERVICES PROVIDED TO IMPROVE THE HEALTH OF OUR COMMUNITY. THIS CARE WAS PROVIDED WITH COMMUNITY BENEFIT MOTIVATIONS. THE AUDITED FINANCIAL STATEMENTS DO NOT INCLUDE A SEPARATE FOOTNOTE REGARDING BAD DEBT EXPENSE.PATIENT RECEIVABLES AND CREDIT POLICY FINANCIAL STATEMENT FOOTNOTEPATIENT ACCOUNTS RECEIVABLE ARE UNCOLLATERALIZED PATIENT OBLIGATIONS THAT ARE STATED AT THE AMOUNT MANAGEMENT EXPECTS TO COLLECT FROM OUTSTANDING BALANCES. THESE OBLIGATIONS ARE PRIMARILY FROM LOCAL RESIDENTS, MOST OF WHOM ARE INSURED UNDER THIRD-PARTY PAYOR AGREEMENTS. THE HOSPITAL BILLS THIRD-PARTY PAYORS ON THE PATIENTS' BEHALF, OR IF A PATIENT IS UNINSURED, THE PATIENT IS BILLED DIRECTLY. ONCE CLAIMS ARE SETTLED WITH THE PRIMARY PAYOR, ANY SECONDARY INSURANCE IS BILLED, AND PATIENTS ARE BILLED FOR COPAY AND DEDUCTIBLE AMOUNTS THAT ARE THE PATIENTS' RESPONSIBILITY. PAYMENTS ON PATIENT ACCOUNTS RECEIVABLE ARE APPLIED TO THE SPECIFIC CLAIM IDENTIFIED ON THE REMITTANCE ADVICE OR STATEMENTTHE HOSPITAL DOES HAVE A POLICY TO CHARGE INTEREST ON ACCOUNTS NEEDING EXTENDED PAYMENT BEYOND ONE YEAR. THE HOSPITAL WILL SET UP LONG-TERM PAYMENT PLANS FOR THESE TYPES OF ACCOUNTS. THESE PATIENTS SIGN AN AGREEMENT WITH THE HOSPITAL TO REPAY THE BALANCE IN APPROXIMATELY TWO YEARS AND WILL BE ASSESSED INTEREST AT A RATE OF 0.833% PER MONTH OR 10% ANNUAL INTEREST ON THE BALANCES OUTSTANDING.THE CARRYING AMOUNTS OF PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY ALLOWANCES THAT REFLECT MANAGEMENT'S BEST ESTIMATE OF THE AMOUNTS THAT WILL NOT BE COLLECTED. MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH A REDUCTION TO GROSS PATIENT SERVICE REVENUE AND A CREDIT TO PATIENT 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 PATIENT ACCOUNTS RECEIVABLE.PATIENT ACCOUNTS RECEIVABLE ARE RECORDED IN THE ACCOMPANYING BALANCE SHEETS NET OF CONTRACTUAL ADJUSTMENTS AND AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. PART III, LINE 8: MEMORIAL HOSPITAL IS DESIGNATED A CRITICAL ACCESS HOSPITAL AND AS SUCH A PORTION OF ITS REVENUES ARE PAID UNDER A COST REIMBURSEMENT SYSTEM. BASED ON THE INSTRUCTIONS, THE TOTAL MEDICARE REVENUE SHOWN ON THIS FORM 990 INCLUDES ONLY A PORTION OF THE GROSS MEDICARE REVENUE THAT IS ACTUALLY RECEIVED BY THE HOSPITAL FROM THE MEDICARE PROGRAM. THE AMOUNTS LISTED FOR MEDICARE DO NOT INCLUDE PHYSICIAN AND MID-LEVEL PRACTITIONER SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT MEMORIAL HOSPITAL OR ANESTHESIA SERVICES. PHYSICIAN COVERAGE IS REIMBURSED PRIMARILY ON A FEE SCHEDULE REIMBURSEMENT METHODOLOGY AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY AND ANESTHESIA SERVICES PROVIDED TO MEDICARE PATIENTS ARE VITAL TO THE WELL-BEING OF THE COMMUNITY AND AS SUCH THESE COSTS AND SHORTFALLS SHOULD ALSO BE CONSIDERED AS AN ADDITIONAL BENEFIT THAT MEMORIAL HOSPITAL PROVIDES TO THE COMMUNITY AND SURROUNDING AREA OF NEILLSVILLE, WISCONSIN. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON AN OVERALL AVERAGE COST TO CHARGE RATIO AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUES (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE) DIVIDED BY TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT EXPENSE. THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES WHICH ARE REIMBURSED ON A COST METHODOLOGY EXCLUDING THE FEE SCHEDULE ITEMS LIKE PHYSICIAN AND MID-LEVEL PRACTITIONER SERVICES WHICH THE HOSPITAL WOULD SHOW A LARGE LOSS ON THESE SERVICES.WHETHER THERE IS A SHORTFALL OR SURPLUS FROM SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THE RECIPIENTS ARE TYPICALLY ELDERLY AND/OR DISABLED MEMBERS OF THE COMMUNITY AND 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: UNINSURED PATIENTS ARE GIVEN THE OPPORTUNITY TO FILL OUT AN APPLICATION FOR CHARITY CARE AT THE TIME OF ADMISSION AND ALL PATIENTS ARE ASKED TO FILL OUT A CHARITY CARE APPLICATION DURING THE COLLECTION PROCESS PRIOR TO SENDING TO ANY ACCOUNTS TO A COLLECTION AGENCY. IF THE PAPERWORK IS NOT RECEIVED, THE ACCOUNT IS HANDLED THROUGH THE NORMAL COLLECTION PROCESS. MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 13G: A LETTER DESCRIBING THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY IS SENT TO PATIENTS FOR EVERY SERVICE PROVIDED WHERE THEY REGISTERED AS PRIVATE PAY. A LETTER IS ALSO SENT TO PATIENTS AGAIN WHEN NO PAYMENT HAS BEEN RECEIVED AFTER TWO STATEMENTS. MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 19D: MAXIMUM AMOUNTS THAT CAN BE CHARGED TO INDIVIDUALS ARE AS FOLLOWS:PATIENTS WHOSE INCOME IS 49% OF LESS OF THE FEDERAL POVERTY GUIDELINES RECEIVE FREE CARE.PATIENTS WHOSE INCOME IS BELOW 200% OF THE FEDERAL POVERTY GUIDELINES RECEIVE THE LOWEST NEGOTIATED COMMERCIAL RATE.PATIENTS WHOSE INCOME IS BELOW 300% OF THE FEDERAL POVERTY GUIDELINES RECEIVE A 10% DISCOUNT FROM GROSS CHARGES. PART VI, LINE 2: DURING 2009 MEMORIAL HOSPITAL, INC ENTERED INTO A FORMAL COMMUNITY NEEDS ASSESSMENT WITH CLARK COUNTY IN ORDER TO SPECIFICALLY ADDRESS PUBLIC HEALTH, WIC, SCHOOLS, ORGANIZATIONS ADVOCATING FOR THE ELDERLY ETC. AND MAINTAIN MEMBERSHIPS IN OTHER COMMUNITY ORGANIZATIONS TO STAY IN TOUCH WITH THE COMMUNITY. ALSO DURING 2009 MEMORIAL HOSPITAL, INC STARTED A COMMUNITY HEALTH COUNCIL THAT MEETS QUARTERLY. THIS COUNCIL IS COMPRISED OF APPROX 30 COMMUNITY MEMBERS REPRESENTING OUR FULL SERVICE AREA. THE PURPOSE OF THIS GROUP IS TO GAIN DIRECT INPUT FROM COMMUNITY MEMBERS ON UNMET HEALTH NEEDS AND POSSIBLE SOLUTIONS TO FILL GAPS. PART VI, LINE 3: ALL PATIENTS WHO REGISTER WITH NO INSURANCE ARE SENT A PRIVATE PAY LETTER NOTIFYING THEM TO CONTACT A FINANCIAL SERVICES REPRESENTATIVE AT MEMORIAL HOSPITAL, INC. IF THEY NEED HELP IN PAYING THEIR BILL. THE LETTER ALSO HIGHLIGHTS THE CHARITY CARE PROGRAM AND GIVES THE WEBSITE WHERE THE APPLICATION CAN BE FOUND. THE FINANCIAL SERVICES REPRESENTATIVE THEN DISCUSSES THE OPTIONS AVAILABLE TO THE PATIENT. PART VI, LINE 4: MEMORIAL HOSPITAL, INC SERVES IN A COUNTY IN WHICH 28% OF THE POPULATION EARNS LESS THAN 200% OF THE FEDERAL POVERTY LEVEL AND 25% OF THE POPULATION ARE UNINSURED. THE COMMUNITY HAS A HIGH POPLULATION OF ELDERLY AND AMISH/MENNONITE. TRANSPORTATION IS HIGHLY UNDER-DEVELOPED AND UNAVAILABLE. THE COUNTY IS DESIGNATED AS A HEALTH PROFESSIONAL SHORTAGE AREA AND MEDICALLY UNDERSERVED AREA. MEMORIAL HOSPITAL, INC SERVES ROUGHLY A 25 MILE RADIUS WITH A POPULATION TOTAL OF 15,000. PART VI, LINE 5: WHILE THERE IS GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFIT HOSPITAL'S COMMUNITY BENEFIT, THIS IS A WORK IN PROGRESS. OUR HOSPITAL PROVIDES CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS. BUT IN ADDITION, WE BELIEVE THAT WE PROVIDE A CRITICALLY IMPORTANT COMMUNITY BENEFIT WHICH IS NOT QUANTIFIED. OUR HOSPITAL, LIKE MOST RURAL HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY. BEYOND INPATIENT HOSPITALIZATIONS, WE PROVIDE LOCAL ACCESS TO MANY HEALTH SERVICES: BIRTHING CENTER, DIAGNOSTICS, EMERGENCY SERVICES & URGENT CARE, HOME CARE, INFUSION SERVICES, LABORATORY SERVICES, OCCUPATIONAL HEALTH, REHABILITATION SERVICES, SPECIALTY MEDICINE, SLEEP CENTER, SPEECH AND AUDIOLOGY, SURGICAL SERVICES, AND WOMENS HEALTH SERVICES. REPORTS FILED WITH STATES PART VI, LINE 7 WI X X X X X 0 1 0 1 0 0 0 0 0 DR JAMES STANGA 129689 0 186069 0 153 0 4500 0 19067 0 339478 0 0 0 DR KENNETH WEIMER 153757 0 53165 0 92 0 4500 0 21528 0 233042 0 0 0 DR TIM MEYER 197208 0 165706 0 153 0 4500 0 6781 0 374348 0 0 0 SCOTT POLENZ 177853 0 12731 0 153 0 4500 0 20567 0 215804 0 0 0 DR GRACE CRUZ-APOLINARIO 190460 0 277370 0 153 0 4500 0 19067 0 491550 0 0 0 DRDAVID PAUSTIAN 216798 0 616110 0 153 0 4500 0 14329 0 851890 0 0 0 DR AMY COULTHARD 157694 0 49603 0 92 0 2412 0 7409 0 217210 0 0 0 DR CAROLYN HARDESTY 144391 0 68462 0 82 0 4500 0 14328 0 231763 0 0 0 DR RANDE SHORT 146941 0 16497 0 219 0 0 0 5348 0 169005 0 0 0 PART I, LINE 4B IN 2011, THE FOLLOWING INDIVIDUALS PARTICIPATED IN A 457(F) PLAN BUT DID NOT RECEIVE ANY PAYMENTS - DR. GRACE CRUZ-APOLINARIO AND DR. TIMITHY MEYER. PART I, LINE 5 IN 2011, THE FOLLOWING PHYSICIANS RECEIVED COMPENSATION THAT WAS PARTLY BASED ON THE GROSS CHARGES RECOGNIZED FOR THEIR PROFESSIONAL SERVICES. DR. JAMES STANGA $106,320 DR. DAVID PAUSTIAN $541,446 DR. TIMOTHY MEYER $118,770 DR. GRACE CRUZ-APOLINARIO $254,993 DR. AMY COULTHARD $ 25,582 DR. CARYLYN HARDESTY $ 15,685 FORM 990, PART VI, SECTION B, LINE 11 THE CFO DETAIL REVIEWS THE FORM BEFORE SUBMISSION. ALSO, BEFORE THE RETURN WAS FILED, A PRELIMINARY COPY WAS PROVIDED TO THE BOARD OF DIRECTORS FOR REVIEW AND COMMENTS. FORM 990, PART VI, SECTION B, LINE 12C MEMORIAL HOSPITAL RELIES ON THE ANNUAL DISCLOSURE OF KEY INDIVIDUALS TO THE BOARD OF DIRECTORS AND MONITORS PURCHASES AND ABSTENTIONS FROM NECESSARY VOTES THROUGHOUT THE YEAR. ALL MANAGERS AND MEDICAL STAFF ARE REQUIRED TO DISCLOSE AND FOLLOW THE CONFLICT OF INTEREST POLICY. FORM 990, PART VI, SECTION B, LINE 15 A COMMITTEE OF THE BOARD OF DIRECTORS HAS BEEN DESIGNATED TO REVIEW ALL EXECUTIVE PAY CHANGES. MARKET DATA IS PROVIDED TO THE COMMITTEE IN THEIR EVALUATION OF PAY CHANGES. COMPARABILITY DATA WAS USED AND THE RESULTS OF ANY EXECUTIVE PAY CHANGES WERE DOCUMENTED. NO ONE WITH A CONFLICT OF INTEREST WAS INCLUDED IN THE DECISION MAKING OF EXECUTIVE COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 ALL DOCUMENTS ARE AVAILABLE UPON REQUEST. DOCUMENTS ARE ALSO DISCUSSED AT COMMUNITY MEETINGS AND EMPLOYEE FORUMS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -19,709. FORM 990, PART XII, LINE 2C THE BOARD OF DIRECTORS IS RESPONSIBLE FOR THE SELECTION OF AN INDEPENDENT AUDITOR AND MANAGEMENT OVERSEES THE AUDIT PROCESS. THIS PROCESS HAS NOT CHANGED IN 2011. COUNTRY VIEW INC 216 SUNSET PLACE NEILLSVILLE WI 54456 391411586 HUD HOUSING WI 501(C)(3) 9 MEMORIAL HOSPITAL INC 1 THE FOUNDATION OF MEMORIAL HOSPITAL INC 216 SUNSET PLACE NEILLSVILLE WI 54456 383800811 FUNDRAISING WI 501(C)(3) 7 MEMORIAL HOSPITAL INC 1 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 1 0 0