2012-11-15T11:01:22-06:00 2011-12-31 861065772 DELOITTE TAX LLP 111 MONUMENT CIRCLE SUITE 2000 INDIANAPOLIS IN 462045108 990 2011-01-01 356001540 GOSHEN HOSPITAL ASSOCIATION INC GOSH 5745352665 200 HIGH PARK AVENUE GOSHEN IN 46526 AMY FLORIA 5745352661 2012-11-15 1 SHAWNA M JIMENEZ P01222873 3174648600 2011 2016-02-24 21:20:13Z IU HEALTH GOSHEN HOSPITAL JAMES DAGUE 2024 S MAIN ST GOSHEN IN 46526 209643720 0 X WWW.GOSHENHEALTH.COM X 1946 IN TO IMPROVE THE HEALTH OF OUR COMMUNITIES BY PROVIDING INNOVATIVE, OUTSTANDING CARE AND SERVICES. 14 10 1377 340 1924 0 175927 158830 184695165 200406955 1380192 5421558 4046145 3656377 190297429 209643720 203000 260500 0 0 70200359 76970083 0 0 0 104312949 117865606 174716308 195096189 15581121 14547531 196983221 207700119 66823409 69536171 130159812 138163948 X THE MISSION OF IU HEALTH GOSHEN HOSPITAL IS TO IMPROVE THE HEALTH OF OUR COMMUNITIES BY PROVIDING INNOVATIVE, OUTSTANDING CARE AND SERVICES, THROUGH EXCEPTIONAL PEOPLE DOING EXCEPTIONAL WORK. 0 0 164606973 260500 202040068 IU HEALTH GOSHEN HOSPITAL IS A NON-DENOMINATIONAL NON-FOR-PROFIT ORGANIZATION PROVIDING HEALTH CARE SERVICES FOR THE GENERAL PUBLIC AS WELL AS CHARITY WITHIN THE COMMUNITY. SEE SCHEDULE O FOR ADDITIONAL DETAIL.THE MISSION OF IU HEALTH GOSHEN HOSPITAL IS TO IMPROVE THE HEALTH OF OUR COMMUNITIES BY PROVIDING INNOVATIVE, OUTSTANDING CARE AND SERVICE, THROUGH EXCEPTIONAL PEOPLE DOING EXCEPTIONAL WORK.THE HOSPITAL'S VALUES INCLUDE: COMPASSION - AND COMMITMENT TO SERVICE WITH EMPATHY. ACCOUNTABILITY - WITH INTEGRITY AND ACTION. RESPECT - THROUGH TREATING OTHERS AS YOU WISH TO BE TREATED. EXCELLENCE - IN ALL WE DO.BUILDING UPON OUR HERITAGE AND VALUES, IU HEALTH GOSHEN HOSPITAL WILL DELIVER EXCEPTIONAL HEALTHCARE IN AN INTEGRATED MODEL TO THE COMMUNITIES WE SERVE, ACHIEVING PREEMINENCE WITH COMMITMENT TO QUALITY, LEADERSHIP, AND INNOVATION. BY 2015, WE WILL ACHIEVE ALL ELEMENTS OF THIS VISION BY FOCUSING ON THE FOLLOWING KEY AREAS:- PROVIDING HIGH-QUALITY CARE WITH COMPASSION, VALUE AND STATE-OF-THE-ART TECHNOLOGY;- CREATING AN ENVIRONMENT THAT FOSTERS THE HIGHEST LEVEL OF ENTHUSIASM, COMMITMENT, COLLABORATION AND SATISFACTION;- STRATEGICALLY RESPONDING TO OUR DIVERSE COMMUNITY'S CHANGING HEALTHCARE NEEDS, WITH INCREASING EMPHASIS ON WELLNESS; AND- HELPING OUR COMMUNITIES TO BE THE "BEST PLACES" TO LIVE AND WORK.AS A COMMUNITY HOSPITAL, IU HEALTH GOSHEN HOSPITAL IS DEDICATED TO MEETING THE SPECIFIC HEALTH CARE NEEDS OF OUR COMMUNITIES. AS A COMMUNITY LEADER, THE HOSPITAL IS COMMITTED TO PROVIDE CARE IN AN INNOVATIVE AND DYNAMIC ENVIRONMENT. THE HOSPITAL HAS 123 PATIENT BEDS AND OVER 146 PHYSICIANS ON ITS MEDICAL STAFF IN NEARLY 33 SPECIALTIES. THESE PHYSICIANS, TOGETHER WITH OTHER DEDICATED PROFESSIONALS, PROVIDE A WIDE RANGE OF SERVICES INCLUDING THE FOLLOWING: ACUTE MEDICAL & SURGICAL, EMERGENCY, HOME HEALTH, RADIOLOGY, LABORATORY, CANCER CARE, BARIATRICS, WOMEN'S HEALTH, PAIN MANAGEMENT, SLEEP STUDIES, REHABILITATION, PATIENT AND COMMUNITY HEALTH EDUCATION AND PROFESSIONAL EDUCATION.IU HEALTH GOSHEN HOSPITAL HAS CONSISTENTLY MET NATIONAL QUALITY STANDARDS. THE HOSPITAL COMPOSITE SCORES FOR PUBLICLY REPORTED QUALITY MEASURES IN THE AREAS OF ACUTE MYOCARDIAL INFARCTION, PNEUMONIA, HEART FAILURE, SURGICAL CARE IMPROVEMENT PROJECT, AND HOSPITAL OUTPATIENT EXCEED 95% IN 2011. IN ADDITION, HEALTHCARE EXCEL (QUALITY IMPROVEMENT ORGANIZATION FOR INDIANA) REPORTED THAT THE HOSPITAL WAS ABOVE OUR PEER GROUP AND OVERALL STATE PERFORMANCE IN ALL AREAS OF OUR PUBLICLY REPORTED MEASURES FOR THE 4 QUARTERS ENDING MARCH 31, 2011.THE AMERICAN NURSES CREDENTIALING CENTER'S (ANCC) MAGNET RECOGNITION PROGRAM FOR EXCELLENCE IN NURSING SERVICES HAS DESIGNATED IU HEALTH GOSHEN HOSPITAL AS A MAGNET HOSPITAL. DESIGNATED HOSPITALS HAVE SUCCESSFULLY CREATED A WORK ENVIRONMENT THAT NURSES FIND BOTH PERSONALLY AND PROFESSIONALLY REWARDING, ADVANCING THE PRACTICE OF NURSING AND IMPROVING PATIENT OUTCOMES. RESEARCH SHOWS THAT MAGNET HOSPITALS ARE MORE EFFECTIVE AT ATTRACTING AND KEEPING QUALITY NURSES. IU HEALTH GOSHEN HOSPITAL IS AMONG AN ELITE GROUP OF ONLY 2% OF HOSPITALS IN THE NATION TO BE RE-DESIGNATED AS A MAGNET FACILITY AND THE ONLY FACILITY IN THE REGION.THE GOSHEN CENTER FOR CANCER CARE IS ACCREDITED BY THE COMMISSION ON CANCER OF THE AMERICAN COLLEGE OF SURGEONS (COC). RECEIVING CARE AT A COC-APPROVED CENTER FOR CANCER CARE ASSURES THAT PATIENTS WILL HAVE ACCESS TO:- QUALITY CARE CLOSE TO HOME.- COMPREHENSIVE CARE OFFERING A RANGE OF STATE-OF-THE ART SERVICES AND EQUIPMENT.- A MULTIDISCIPLINARY TEAM APPROACH TO COORDINATE THE BEST TREATMENT OPTIONS AVAILABLE TO CANCER PATIENTS.- PARTICIPATION IN CANCER CLINICAL TRIALS, EDUCATION AND SUPPORT.- LIFELONG PATIENT FOLLOW-UP THROUGH A CANCER REGISTRY THAT COLLECTS DATA ON TYPE AND STAGE OF CANCERS AND TREATMENT RESULTS.- ONGOING MONITORING AND IMPROVEMENT IN CARE.THE CENTER FOR CANCER CARE IS A LEADER IN INNOVATIVE CANCER TREATMENT. WE WERE AMONG THE FIRST TO ADOPT A COMPREHENSIVE, MULTIDISCIPLINARY APPROACH TO CANCER TREATMENT. WE OFFER HOLISTIC PROGRAMS FOR STRENGTHENING MINDS AS WELL AS BODIES, PLACE A PREMIUM ON FAMILY INVOLVEMENT AND SPIRITUAL NEEDS, AND ENCOURAGE PATIENTS TO PLAY A DECISION-MAKING ROLE IN TREATMENT SELECTION. THE CENTER FOR CANCER CARE HAS SPECIALLY TRAINED SURGICAL ONCOLOGISTS, A BREAST SURGEON, MEDICAL ONCOLOGIST, A RADIATION ONCOLOGIST, NATUROPATHIC PRACTITIONERS AND HIGHLY DISTINGUISHED MAGNET DESIGNATED NURSES.IU HEALTH GOSHEN HOSPITAL IMPROVES THE HEALTH AND WELL-BEING OF ITS COMMUNITIES BY PROVIDING COMMUNITY WELLNESS AND EDUCATION PROGRAMS. THROUGH LOCAL PARTNERSHIPS, THE HOSPITAL IDENTIFIES HEALTH ISSUES AND CREATES PROGRAMS TO ENSURE OUR COMMUNITY IS THE HEALTHIEST PLACE TO LIVE, WORK AND RAISE A FAMILY. THE FIRST OF THESE PROGRAMS COVER CPR, EMS, DIABETES, CHILDBIRTH, FITNESS, NUTRITION, COMMUNITY EDUCATION AND HEALTH SCREENINGS AND ELKHART COUNTY CHILDHOOD OBESITY INITIATIVE. THE CPR CLASS IS FOR ANYONE - PROFESSIONALS OR PRIVATE CITIZENS - WHO WANT TO KNOW HOW TO PERFORM LIFE-SAVING CARDIOPULMONARY RESUSCITATION; FIRST AID CLASSES ARE ALSO OFFERED. EMS TRAINING IS AVAILABLE FOR PERSONS INTERESTED IN BECOMING EMERGENCY MEDICAL TECHNICIANS OR FIREFIGHTERS. THE DIABETES EDUCATION HELPS PEOPLE DELAY THE ONSET AND SLOW THE PROGRESSION OF COMPLICATIONS FROM THIS DISEASE. IT INCLUDES SEMINARS, SUPPORT GROUPS, CONSULTATIONS AND SCREENINGS. CHILDBIRTH EDUCATION PREPARES EXPECTANT MOTHERS AND THEIR FAMILIES DURING THIS SIGNIFICANT TIME IN THEIR LIFE. CLASSES REVIEW MANY ASPECTS OF CHILDBIRTH INCLUDING LABOR REHEARSAL, CESAREAN DELIVERIES, SINGLE-TEEN ISSUES, BREAST FEEDING AND A CLASS JUST FOR SIBLINGS. IN ADDITION TO VARIOUS COMMUNITY WELLNESS AND EDUCATION PROGRAMS, IU HEALTH GOSHEN HOSPITAL PROVIDES A FULL-SERVICE RESOURCE FOR COMPREHENSIVE HEALTH INFORMATION AND ASSISTANCE. NURSE ON CALL (NOC) IS FULL-SERVICE, MULTI-LINGUAL HEALTH INFORMATION, REFERRAL AND NURSE TRIAGE TELEPHONE SERVICE AVAILABLE 24 HOURS A DAY, 7 DAYS WEEK. NOC IS STAFFED BY SPECIALLY TRAINED, KNOWLEDGEABLE AND EXPERIENCED REGISTERED NURSES. THIS FREE SERVICE PROVIDES MEDICAL GUIDANCE WHEN SICK OR INJURED, INFORMATION ON PHYSICIANS IN THE AREA, REFERRALS TO COMMUNITY RESOURCES AND REGISTRATION FOR CLASSES AND EVENTS. ANNUALLY, IU HEALTH GOSHEN HOSPITAL MAKES CONTRIBUTIONS TO WELL-DESERVING ORGANIZATIONS FROM GOSHEN AND THE SURROUNDING COMMUNITIES. THE HOSPITAL SUPPORTS AREA NON-PROFIT AGENCIES THAT SHARES ITS MISSION, VISION AND VALUES THROUGH THE COMMUNITY BENEFIT FUND. THE PROGRAM IS AN EFFORT TO FURTHER THE IMPACT THESE ORGANIZATIONS CAN MAKE AND INCREASE THE NUMBER OF BENEFICIAL PROGRAMS AVAILABLE TO THE COMMUNITY. IN 2011, THE HOSPITAL PROVIDED OVER $329,500 TO 52 ORGANIZATIONS. SINCE ITS INCEPTION IN 1998, THE COMMUNITY BENEFIT FUND HAS GIVEN OVER $1.7 MILLION IN GRANT MONEY. IU HEALTH GOSHEN HOSPITAL PROVIDES HEALTH CARE SERVICES TO ALL MEMBERS OF THE COMMUNITIES REGARDLESS OF THEIR ABILITY TO PAY. THE HOSPITAL OFFERS FINANCIAL ASSISTANCE TO THOSE PATIENTS UNABLE TO PAY ALL OR A PORTION OF THEIR BILL AND WHO ARE UNABLE TO QUALIFY FOR ASSISTANCE THROUGH FEDERAL AND STATE GOVERNMENT ASSISTANCE PROGRAMS. PATIENTS ARE ASKED TO COMPLETE A FINANCIAL AID APPLICATION TO DETERMINE THEIR ELIGIBILITY FOR FINANCIAL ASSISTANCE. THE HOSPITAL PROVIDES THE ASSISTANCE OF A FINANCIAL ADVOCATE TO HELP PATIENTS COMPLETE THIS APPLICATION AND TO INVESTIGATE OTHER FORMS OF AVAILABLE ASSISTANCE. IN 2011, THE HOSPITAL EXTENDED CHARITY CARE TO OVER 3,924 PATIENTS TOTALING $8.4 MILLION. IU HEALTH GOSHEN HOSPITAL ALSO PARTNERS WITH A LOCAL FINANCIAL INSTITUTION TO PROVIDE A FLEXIBLE AND AFFORDABLE FINANCING SOLUTION FOR A PATIENT'S MEDICAL CARE.IU HEALTH GOSHEN HOSPITAL RECEIVED THE GOLD PERFORMANCE ACHIEVEMENT AWARD BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION'S NCDR ACTION REGISTRY (2011) - ONE OF ONLY 167 HOSPITALS NATIONWIDE TO EARN THE DISTINCTION. IU HEALTH GOSHEN HOSPITAL WAS NAMED AMONG "100 BEST PLACES TO WORK IN HEALTHCARE" BY HOSPITAL REVIEW MAGAZINE.IU HEALTH GOSHEN HOSPITAL WAS RECOGNIZED BY THE AMERICAN COLLEGE OF SURGEONS THROUGH THEIR NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM AS ONE OF 26 HOSPITALS ACHIEVING EXEMPLARY PERFORMANCE FOR SURGICAL PATIENT CARE.IU HEALTH GOSHEN HOSPITAL'S IT DEPARTMENT WAS NAMED TO HEALTHCARE IT NEWS' "WHERE TO WORK: BEST HOSPITAL IT DEPARTMENTS" LIST AS ONE OF THE TOP 10 BEST OF MEDIUM-SIZED HOSPITALS.IU HEALTH GOSHEN HOSPITAL WAS NAMED AN ACCREDITED HEART FAILURE INSTITUTE BY THE NATIONAL HEALTHCARE ACCREDITATION COLLOQUIUM. 164606973 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 114 0 1 1377 1 1 1 0 0 0 0 0 0 0 0 0 X 14 10 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IN X DIRECTOR OF FINANCE 5745352665 200 HIGH PARK AVENUE GOSHEN IN 46526 X JAMES DAGUE 40.00 X X 1167072 0 24383 LINDA BAXLEY 1.00 X X 0 0 0 JESSE BERGER 1.00 X 0 0 0 RAO BETINA MD 1.00 X 0 0 0 DERALD BONTRAGER 1.00 X X 0 0 0 EDWARD BOYTS MD 1.00 X 0 203301 28846 DANIEL BRUETMAN MD 1.00 X 0 496762 30314 RANDY CRIPE 1.00 X 0 0 0 KEVIN DEARY 1.00 X 0 0 0 CHRISTOPHER GRAFF 1.00 X 0 0 0 DAVID KORONKIEWICZ DO 1.00 X 0 336607 29968 DON OGLE 1.00 X 0 0 0 JACKIE PARK 1.00 X 0 0 0 KAREN PLETCHER 1.00 X 0 0 0 MARTHA SUZIE YEAGER 1.00 X 0 0 0 DAN BERGER MD 1.00 X 0 165229 17983 AMY FLORIA 40.00 X 337545 0 26290 RANDY CHRISTOPHEL 40.00 X 588307 0 30906 ALAN WELDY 40.00 X 420317 0 24479 POOPALASINGHAM POOVENDRAN MD 40.00 X 565290 0 25315 JOSEPH GAGLIARDI 40.00 X 436546 0 11519 RANDALL CAMMENGA MD 40.00 X 414191 0 22993 MIN YAN MD 40.00 X 315937 0 17918 PAMELA KARSEN 40.00 X 298828 0 12205 4544033 1201899 303119 35 0 1 0 HEALTH TRAN DBA BENESCRIPT 8300 EAST MAPLEWOOD AVENUE SUITE 1 GREENWOOD VILLAGE CO 80111 COLLEAGUE DRUG BENEFIT 2075255 GERIG SURGICAL 303 SOUTH MAIN STREET MISHAWAKA IN 46544 ON CALL SERVICES 1089484 CUMMINS CROSSPOINT PO BOX 663811 INDIANAPOLIS IN 46266 REPAIR SERVICES 588246 GLOBAL PHYSICS SOLUTIONS PO BOX 809153 CHICAGO IL 606809153 PHYSICS SERVICES 564000 INDIANA LAKES MANAGED CARE 200 HIGH PARK AVENUE GOSHEN IN 46526 ACCESS FEES 361889 14 158830 158830 PATIENT CARE 621110 200406955 200406955 200406955 5421558 1924 5419634 1086414 0 1086414 1086414 1086414 FOOD SERVICE REVENUE 721000 936850 936850 FINANCE CHARGES 561000 217470 217470 OTHER ONCOLOGY REV MIS 621500 190501 190501 1225142 1225142 2569963 209643720 202040068 1924 7442898 260500 260500 2513241 2513241 55804090 37906265 17897825 3931057 2555187 1375870 10852725 7054271 3798454 3868970 2514831 1354139 1162774 1162774 282909 282909 43541 43541 18234721 18234721 4371861 4371861 974462 974462 1458966 1458966 1381618 1381618 746455 746455 2104004 2104004 8276251 8276251 10076011 10076011 1441818 1441818 DRUGS AND MEDICAL SUPPL 37858665 37858665 0 0 BAD DEBT 19379205 19379205 0 0 REPAIRS & MAINTENANCE 5024911 5024911 0 0 EQUIPMENT RENTAL 1976331 1976331 3071103 3071103 195096189 164606973 30489216 0 6293820 12472332 16068380 11282149 25361491 27017971 523731 860326 5275839 4577268 2730703 2555123 198144645 97659723 94018792 100484922 45879836 47774955 110922 0 719707 675073 196983221 207700119 18463427 22615615 46386972 44970675 1973010 1949881 66823409 69536171 X 129697959 137554991 461853 608957 130159812 138163948 196983221 207700119 X 14547531 -6543395 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2988795 3883888 6872683 86919191 27620526 59298665 377005 113748 152160 338593 95249793 69887037 25362756 8612225 8612225 100484922 BOARD DESIGNATED FUNDS 46420047 F CANCER CENTER INVESTMENT 1354908 F 47774955 ASSET RETIREMENT OBLIGATION 269410 DEFERRED COMPENSATION 437602 DEFERRED MALPRACTICE CLAIMS 256460 INTEREST RATE SWAP 986409 1949881 1 1 X 1 X 1 X 1 1 1 0 1 1 3494774 3494774 0.01990 15028635 7109023 7919612 0.04510 18523409 7109023 11414386 0.06500 876669 40185 836484 0.00480 216267 450 215817 0.00120 240171 240171 0.00140 720476 720476 0.00410 2053583 40635 2012948 0.01150 20576992 7149658 13427334 0.07650 53613 53613 0.00030 3434 170 3264 0.00000 4018 4018 0.00000 4428 4428 0.00000 782 782 0.00000 67437 67437 0.00040 133712 170 133542 0.00070 1 6432793 1260077 38621221 46686196 -8064975 X 1 1 1 1 IU HEALTH GOSHEN HOSPITAL

200 HIGH PARK AVENUE GOSHEN IN 46526

X X X IU HEALTH GOSHEN HOSPITAL 1 1 1 200.000000000000 1 400.000000000000 1 X X 1 1 X X 1 0 1 X 0 0 4 NEW PARIS MEDICAL CLINIC

2018 SOUTH MAIN STREET GOSHEN IN 46526

CLINIC INDIANA LAKES MANAGED CARE

2018 SOUTH MAIN STREET GOSHEN IN 46526

HEALTH CARE MANAGEMENT THE RETREAT WOMEN'S HEALTH CENTER

1135 PROFESSIONAL DRIVE GOSHEN IN 46526

CLINIC IU HEALTH GOSHEN

200 HIGH PARK AVENUE GOSHEN IN 46526

CLINIC PART I, L7 COL(F): A COST-TO-CHARGE RATIO DERIVED FROM SCHEDULE H, WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES, WAS USED TO DETERMINE COSTS FOR LINES A THROUGH C REPORTED IN THE TABLE. PART III, LINE 4: A DETAILED COLLECTION POLICY IS FOLLOWED. BAD DEBT COSTS ARE BASED UPON MANAGEMENT'S ASSESSMENT OF EXPECTED COLLECTIONS TAKING INTO CONSIDERATION BUSINESS AND ECONOMIC CONDITIONS. THESE ALLOWANCES ARE PERIODICALLY REVIEWED FOR ACCURACY AND IF ANY FURTHER ACTIONS ARE REQUIRED. THE FOLLOWING NARRATIVE ADDRESSES THE ALLOWANCE FOR DOUBTFUL ACCOUNTS WHICH IS INCLUDED IN THE FOOTNOTES IN THE FINANCIAL STATEMENTS FOR IU HEALTH: THE PROVISION FOR BAD DEBTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTH CARE COVERAGE, AND OTHER COLLECTIONINDICATORS. PERIODICALLY, MANAGEMENT ASSESSES THE ADEQUACY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON ESTIMATED COLLECTIONS BY PAYOR CATEGORY AND AGING. THE RESULTS OF THESE ESTIMATES ARE THEN USED TO MAKE ANY MODIFICATIONS TO THE PROVISION FOR BAD DEBTS TO ESTABLISH AN APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN ADDITION, THE SYSTEM HAS ESTABLISHED GUIDELINES FOR PLACING CERTAIN PAST DUE PATIENT BALANCES WITH COLLECTION AGENCIES. PART III, LINE 8: ACTUAL MONTH TO DATE AND YEAR TO DATE REVENUES, CONTRACTUALS, REVENUE AND ACCOUNTS RECEIVABLE RELATED RATIOS, AND REVENUE RELATED STATISTICS (DAYS, DISCHARGES, ETC.) ARE COMPARED TO BUDGET AND PRIOR YEAR AMOUNTS ON A MONTHLY BASIS BY CFO OF IU HEALTH GOSHEN HOSPITAL DEPARTMENT HEADS AND FINANCIAL REPRESENTATIVES. ADDITIONALLY, ACTUAL CONTRACTUAL ALLOWANCE AS A PERCENTAGE OF GROSS ACCOUNTS RECEIVABLE AND CONTRACTUAL PROVISION AS A PERCENTAGE OF GROSS PATIENT CHARGES COMPARED TO BUDGETED AND PRIOR YEAR AMOUNTS ARE MONITORED. THIS IS DONE AS PART OF THE HOSPITAL'S MONTHLY CLOSE PROCESS. EXPLANATIONS TO VARIANCES (OR NON-VARIANCES WHEN EXPECTED) ARE RESEARCHED AND PROVIDED BY THE APPROPRIATE PERSONNEL AND REVIEWED WITH MANAGEMENT OF THE HOSPITAL. THE FINANCE DEPARTMENT ALSO CONSIDERS THESE KEY PERFORMANCE INDICATORS WHEN DEVELOPING THEIR ESTIMATES OF CONTRACTUAL ALLOWANCES TO ENSURE RECORDED AMOUNTS APPEAR REASONABLE BASED ON ACTUAL DATA AVAILABLE.FINANCIAL REPRESENTATIVES PREPARE AND UPDATE THE CONTRACTUAL ALLOWANCE MODEL A MINIMUM OF THREE TIMES THROUGHOUT THE YEAR AS A BASIS FOR ALL THIRD PARTY PAYORS BASED ON ACTUAL STATISTICS (E.G. DISCHARGES, DAYS, ETC.) AND ON CURRENT REIMBURSEMENT RATES. THE MODEL ANALYZES PATIENT RECEIVABLES AND CONTRACTUAL ALLOWANCE BY PAYOR AND BY PATIENT STATUS. THE MODEL ESTIMATES THE COLLECTABILITY OF PATIENT ACCOUNTS BASED ON HISTORICAL COLLECTION RATES. FINANCE COLLEAGUES ALSO UPDATE THE MODEL TO ACCOUNT FOR CHANGES IN REIMBURSEMENT RULES. AFTER THE MODEL IS PREPARED, IT IS REVIEWED BY THE CHIEF FINANCIAL OFFICER FOR APPROPRIATENESS AND REASONABLENESS.CONTRACTUAL ALLOWANCE CALCULATIONS ARE RECONCILED TO THE GENERAL LEDGER ON A MONTHLY BASIS. ONCE THE CALCULATION IS PREPARED, THE FINANCE DEPARTMENT ADJUSTS THE GENERAL LEDGER ACCOUNTS. PART III, LINE 9B: FINANCIAL ASSISTANCE IS GRANTED TO THOSE PATIENTS UNABLE TO PAY ALL OR A PORTION OF THEIR BILL AND WHO ARE UNABLE TO QUALIFY FOR ASSISTANCE THROUGH FEDERAL AND STATE GOVERNMENT ASSISTANCE PROGRAMS. IF AFTER INSURANCE REIMBURSEMENT ADDITIONAL ASSISTANCE IS NEEDED, ALL PATIENTS MAY OBTAIN FINANCIAL ASSISTANCE IF THE INCOME CRITERIA ARE MET. ALL FINANCIAL ASSISTANCE APPLICATIONS ARE BASED ON POLICY GUIDELINES. UNINSURED PATIENTS ARE REQUIRED TO PROVIDE DOCUMENTATION AND AN APPLICATION. WHEN APPROVED, THE ADJUSTMENT IS APPLIED TO THE PATIENT'S ACCOUNT. FOR PATIENTS WHO DO NOT QUALIFY FOR CHARITY CARE OF FINANCIAL ASSISTANCE, PAYMENT PLANS AND LUMP SUM SETTLEMENTS ARE AVAILABLE. IU HEALTH GOSHEN HOSPITAL ALSO PARTNERS WITH A LOCAL FINANCING INSTITUTION TO PROVIDE A FLEXIBLE AND AFFORDING FINANCING SOLUTION. IU HEALTH GOSHEN HOSPITAL PART V, SECTION B, LINE 11H: FAMILY SIZE IS ANOTHER FACTOR IN DETERMINING AMOUNTS CHARGED TO PATIENTS. PART VI, LINE 2: AS A COMMUNITY HOSPITAL, IU HEALTH GOSHEN HOSPITAL IS DEDICATED TO MEETING THE SPECIFIC HEALTH CARE NEEDS OF OUR COMMUNITY. THE HOSPITAL HAS 123 PATIENT BEDS AND OVER 146 PHYSICIANS ON ITS MEDICAL STAFF IN NEARLY 33 SPECIALTIES. THESE PHYSICIANS, TOGETHER WITH OTHER DEDICATED PROFESSIONALS, PROVIDE A WIDE RANGE OF SERVICES INCLUDING THE FOLLOWING: ACUTE MEDICAL & SURGICAL, EMERGENCY, HOME HEALTH, RADIOLOGY, LABORATORY, CANCER CARE, BARIATRICS, WOMEN'S HEALTH, PAIN MANAGEMENT, SLEEP STUDIES, REHABILITATION, PATIENT AND COMMUNITY HEALTH EDUCATION AND PROFESSIONAL EDUCATION.THE CENTER FOR CANCER CARE IS A LEADER IN INNOVATIVE CANCER TREATMENT. WE WERE AMONG THE FIRST TO ADOPT A COMPREHENSIVE, MULTIDISCIPLINARY APPROACH TO CANCER TREATMENT. WE OFFER HOLISTIC PROGRAMS FOR STRENGTHENING MINDS AS WELL AS BODIES, PLACE A PREMIUM ON FAMILY INVOLVEMENT AND SPIRITUAL NEEDS, AND ENCOURAGE PATIENTS TO PLAY A DECISION-MAKING ROLE IN TREATMENT SELECTION. THE CENTER FOR CANCER CARE HAS SPECIALLY TRAINED SURGICAL ONCOLOGISTS, A BREAST SURGEON, MEDICAL ONCOLOGISTS, A RADIATION ONCOLOGIST, NATUROPATHIC PRACTITIONERS AND HIGHLY DISTINGUISHED MAGNET DESIGNATED NURSES.IU HEALTH GOSHEN HOSPITAL IMPROVES THE HEALTH AND WELL-BEING OF ITS COMMUNITIES BY PROVIDING COMMUNITY WELLNESS AND EDUCATION PROGRAMS. THROUGH LOCAL PARTNERSHIPS, THE HOSPITAL IDENTIFIES HEALTH ISSUES AND CREATES PROGRAMS TO ENSURE OUR COMMUNITY IS THE HEALTHIEST PLACE TO LIVE, WORK AND RAISE A FAMILY. THE FIRST OF THESE PROGRAMS COVER CPR, EMS, DIABETES, CHILDBIRTH, FITNESS, NUTRITION, COMMUNITY EDUCATION AND HEALTH SCREENINGS AND ELKHART COUNTY CHILDHOOD OBESITY INITIATIVE. THE CPR CLASS IS FOR ANYONE - PROFESSIONALS OR PRIVATE CITIZENS - WHO WANT TO KNOW HOW TO PERFORM LIFE-SAVING CARDIOPULMONARY RESUSCITATION; FIRST AID CLASSES ARE ALSO OFFERED. EMS TRAINING IS AVAILABLE FOR PERSONS INTERESTED IN BECOMING EMERGENCY MEDICAL TECHNICIANS OR FIREFIGHTERS. THE DIABETES EDUCATION HELPS PEOPLE DELAY THE ONSET AND SLOW THE PROGRESSION OF COMPLICATIONS FROM THIS DISEASE. IT INCLUDES SEMINARS, SUPPORT GROUPS, CONSULTATIONS AND SCREENINGS. CHILDBIRTH EDUCATION PREPARES EXPECTANT MOTHERS AND THEIR FAMILIES DURING THIS SIGNIFICANT TIME IN THEIR LIFE. CLASSES REVIEW MANY ASPECTS OF CHILDBIRTH INCLUDING LABOR REHEARSAL, CESAREAN DELIVERIES, SINGLE-TEEN ISSUES, BREAST FEEDING AND A CLASS JUST FOR SIBLINGS. IN ADDITION TO VARIOUS COMMUNITY WELLNESS AND EDUCATION PROGRAMS, IU HEALTH GOSHEN HOSPITAL PROVIDES A FULL-SERVICE RESOURCE FOR COMPREHENSIVE HEALTH INFORMATION AND ASSISTANCE. NURSE ON CALL (NOC) IS FULL-SERVICE, MULTI-LINGUAL HEALTH INFORMATION, REFERRAL AND NURSE TRIAGE TELEPHONE SERVICE AVAILABLE 24 HOURS A DAY, 7 DAYS WEEK. NOC IS STAFFED BY SPECIALLY TRAINED, KNOWLEDGEABLE AND EXPERIENCED REGISTERED NURSES. THIS FREE SERVICE PROVIDES MEDICAL GUIDANCE WHEN SICK OR INJURED, INFORMATION ON PHYSICIANS IN THE AREA, REFERRALS TO COMMUNITY RESOURCES AND REGISTRATION FOR CLASSES AND EVENTS. PART VI, LINE 3: UNINSURED PATIENTS ARE SCREENED DURING THE PRE-REGISTRATION PROCESS FOR ELIGIBILITY IN THE HEALTHY INDIANA PLAN AND FOR ANY OTHER KNOWN SOURCES OF FINANCIAL ASSISTANCE. ALL REGISTRATION LOCATIONS HAVE FINANCIAL ASSISTANCE FORMS AVAILABLE FOR SELF-PAY PATIENTS TO COMPLETE AND WILL HAVE INFORMATION ON THE CRITERIA AND PROCESS FOR APPLYING FOR FINANCIAL ASSISTANCE. APPLICATIONS ARE ALSO PROVIDED TO ANY PATIENTS WITH A BALANCE DUE WHO MAY QUALIFY FOR FINANCIAL ASSISTANCE. COUNSELORS ARE AVAILABLE TO PATIENTS TO AID IN THE APPLICATION PROCESS INCLUDING THE COLLECTION OF INFORMATION TO COMPLETE THE APPLICATION. PAYMENT OPTIONS AND INFORMATION ON FINANCIAL ASSISTANCE IS AVAILABLE ON THE HOSPITAL'S WEBSITE. PATIENTS MAY DOWNLOAD A PRELIMINARY APPLICATION, AND THE PATIENT AGREEMENT ASSOCIATED WITH FINANCIAL ASSISTANCE FROM THE WEBSITE. THIS INFORMATION IS AVAILABLE IN ENGLISH AND SPANISH. PART VI, LINE 4: IU HEALTH GOSHEN HOSPITAL SERVES THE NORTHERN INDIANA AREA IN ELKHART COUNTY. ACCORDING TO THE 2011 CENSUS, THE POPULATION OF ELKHART COUNTY IS 200,561. THE MEDIAN INCOME FOR A HOUSEHOLD IN ELKHART COUNTY BASED ON THE 2011 CENSUS IS $34,863 AND THE MEDIAN INCOME FOR A FAMILY IS $51,100. APPROXIMATELY 9.6% OF FAMILIES AND 13.0% OF THE POPULATION WERE BELOW THE POVERTY LINE, INCLUDING 21.8% OF THOSE UNDER THE AGE 18 AND 6.5% OF THOSE AGE 65 AND OVER. THE RACIAL MAKEUP OF THE COUNTY WAS ABOUT 76.9% WHITE, 6.0% AFRICAN AMERICAN, AND 17.1% OTHER RACES. 3.4% OF THE POPULATION IS HISPANIC OR LATINO OR ANY RACE. PART VI, LINE 5: ALL OF THE HOSPITAL'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA. A MAJORITY OF THE BOARD MEMBERS ARE INDEPENDENT OF THE ORGANIZATION. THE GOVERNING BODY APPROVES MEDICAL STAFF PRIVILEGES AS INDICATED IN THE ORGANIZATION'S CREDENTIALING AND PRIVILEGING POLICIES AND AS RECOMMENDED BY THE MEDICAL EXECUTIVE COMMITTEE OF THE HOSPITAL. THE HOSPITAL'S GOVERNING BODY APPROVES THE ANNUAL OPERATING BUDGET FOR THE HOSPITAL AND THE EXPENDITURE OF CAPITAL FUNDS ABOVE CERTAIN DOLLAR AMOUNTS. THE GOVERNING BODY ALSO PARTICIPATES IN STRATEGIC PLANNING INITIATIVES TO DETERMINE GOALS OBJECTIVES FOCUSED ON PATIENT CARE FOR THE COMMUNITY. PART VI, LINE 6: HOSPITAL MANAGEMENT PROVIDES IU HEALTH WITH THE HOSPITAL'S ANNUAL OPERATING BUDGET AND KEY STRATEGIC OBJECTIVES. IN ADDITION, THE HOSPITAL MANAGEMENT PROVIDES IU HEALTH WITH VARIOUS KEY METRICS INVOLVING PATIENT SATISFACTION, PATIENT QUALITY AND COLLEAGUE SATISFACTION. IU HEALTH REVIEWS THE DATA TO ENSURE KEY INITIATIVES ARE FOCUSED TOWARDS THE PROMOTING AND MEETING THE HEALTHCARE NEEDS OF THE COMMUNITIES. IN ADDITION, THE HOSPITAL COLLABORATES WITH IU HEALTH TO PROVIDE NECESSARY NURSING EDUCATION AND PHYSICIAN RECRUITMENT TO ASSIST IN MEETING THE HEALTH NEEDS OF THE COMMUNITY. REPORTS FILED WITH STATES PART VI, LINE 7 IN 1 AMIGO CENTRE 26455 BANKER STURGIS MI 49091 351103269 501(C)(3) 15000 OUTDOOR ENVIRONMENTAL EDUCATION PROGRAM EXPENSES AMISH YOUTH VISION PROJECT PO BOX 191 TOPEKA IN 46571 260865808 501(C)(3) 6000 YOUTH DRUG AND ALCOHOL ABUSE PREVENTION PROGRAM EXPENSES BASHOR CHILDREN'S HOME PO BOX 843 GOSHEN IN 46527 350933555 501(C)(3) 10000 PART TIME ASSISTANCE BIG BROTHERS BIG SISTERS OF ELKHART COUNTY 59029 CR 13 ELKHART IN 46517 351272588 501(C)(3) 6000 SPONSORSHIP EXPENSES BOYS & GIRLS CLUB OF GREATER GOSHEN INC PO BOX 614 GOSHEN IN 46527 351033735 501(C)(3) 20000 SPORTS, PLAY & ACTIVE RECREATION FOR KIDS INITIATIVE CAPS - CHILD AND PARENT SERVICES 1000 W HIVELY ELKHART IN 46517 350888765 501(C)(3) 5000 BABY THINK IT OVER PROGRAM CARE FOUNDATION 1505 S MAIN GOSHEN IN 46526 352111562 501(C)(3) 20000 CARE HOUSE EXPENSES CENTER FOR COMMUNITY JUSTICE 121 S THIRD ST GOSHEN IN 46526 351620204 501(C)(3) 5000 WAGES AND PERSONNEL BENEFITS CENTER FOR HEALING AND HOPE PO BOX 195 GOSHEN IN 46527 020560511 501(C)(3) 10000 DIABETES PREVENTION PROJECT EXPENSES COMMUNITY DENTAL CLINIC 7750 W 200 S TOPEKA IN 46571 352068053 501(C)(3) 6000 DENTAL CARE EXPENSES COUNCIL ON AGING OF ELKHART COUNTY INC 2555 OAKLAND GOSHEN IN 46517 510178910 501(C)(3) 10000 RESOURCE LIBRARY AND ADVOCACY CENTER EXPENSES ELKHART COUNTY CHAPTER OF THE AMERICAN RED CROSS 721 RIVERVIEW ELKHART IN 46516 350909968 501(C)(3) 12000 BASIC AID TRAINING PROGRAM EXPENSES ELKHART COUNTY HEALTH DEPARTMENT - HEALTHY BEGINNINGS DIVISION 1400 HUDSON ELKHART IN 46516 356000142 GOV'T ENTITY 7000 PAYMENTS FOR SALARIES FAMILY CHRISTIAN DEVELOPMENT CENTER PO BOX 227 NAPPANEE IN 46550 351979463 501(C)(3) 5000 MEDICINE ASSISTANCE PROGRAM EXPENSES FAMILY SERVICES OF ELKHART COUNTY INC 101 E HIVELY ELKHART IN 46517 350868079 501(C)(3) 7500 MENTAL HEALTH SERVICES GOSHEN COLLEGE RECREATION CENTER 1700 S MAIN GOSHEN IN 46526 352158366 501(C)(3) 5000 OPERATING EXPENSES GOSHEN COLLEGE DEPARTMENT OF NURSING 1700 S MAIN GOSHEN IN 46526 352158366 501(C)(3) 10000 PAYMENTS FOR SCHOLARSHIPS GOSHEN HIGH SCHOOL ONE REDSKIN GOSHEN IN 46526 356002423 501(C)(3) 10000 SCHOOL-BASED CHILD CARE EXPENSES HABITAT FOR HUMANITY OF ELKHART COUNTY PO BOX 950 GOSHEN IN 46526 351685313 501(C)(3) 5000 GREEN BUILDING COSTS HISPANICLATINO HEALTH COALITION OF ELKHART CO 323 STOCKER ELKHART IN 46516 320039221 501(C)(3) 10000 HEALTH FAIR EXPENSES LACASA INC 202 N COTTAGE GOSHEN IN 46528 351554538 501(C)(3) 20000 VIOLENCE AGAINST WOMEN ACT AND VISA IMMIGRATION DOCUMENT PREP EXPENSES MAPLE CITY HEALTH CARE CENTER 213 MIDDLEBURY GOSHEN IN 46528 351749398 501(C)(3) 20000 HEALTHCARE EXPENSES MDC GOLDENROD 1514 COLLEGE GOSHEN IN 46526 311205424 501(C)(3) 6000 MERIMNA HOMES EXPENSES THE SOURCE 2600 OAKLAND ELKHART IN 46517 351070041 501(C)(3) 10000 SOURCE PROGRAM EXPENSES THE WINDOW 223 S MAIN GOSHEN IN 46526 351155054 501(C)(3) 5000 NUTRIONAL MEAL EXPENSES UNITED CANCER SERVICES OF ELKHART COUNTY INC 23971 US HWY 33 ELKHART IN 46517 351091429 501(C)(3) 15000 UCS PROGRAMS' EXPENSES 26 0 PART I, LINE 2: THE ORGANIZATION'S PROCEDURES FOR MONITORING THE USE OF GRANT FUNDS IN THE U.S. CONSISTS OF REQUIRING THE COMPLETION OF A FOLLOW-UP REPORT FORM WITH THE SUBSEQUENT GRANT FUND APPLICATIONS. X X 1 1 X X X X X 0 1 0 0 0 0 0 0 0 JAMES DAGUE 544190 0 203000 0 419882 0 0 0 24383 0 1191455 0 0 0 EDWARD BOYTS MD 0 148088 0 55213 0 0 0 0 0 28846 0 232147 0 0 DANIEL BRUETMAN MD 0 451150 0 45612 0 0 0 0 0 30314 0 527076 0 0 DAVID KORONKIEWICZ DO 0 335532 0 1075 0 0 0 0 0 29968 0 366575 0 0 DAN BERGER MD 0 98971 0 66258 0 0 0 0 0 17983 0 183212 0 0 AMY FLORIA 249500 0 74520 0 13525 0 0 0 26290 0 363835 0 0 0 RANDY CHRISTOPHEL 352897 0 103959 0 131451 0 0 0 30906 0 619213 0 0 0 ALAN WELDY 311384 0 96420 0 12513 0 0 0 24479 0 444796 0 0 0 POOPALASINGHAM POOVENDRAN MD 549809 0 15481 0 0 0 0 0 25315 0 590605 0 0 0 JOSEPH GAGLIARDI 297597 0 119953 0 18996 0 0 0 11519 0 448065 0 0 0 RANDALL CAMMENGA MD 298278 0 95773 0 20140 0 0 0 22993 0 437184 0 0 0 MIN YAN MD 304939 0 75 0 10923 0 0 0 17918 0 333855 0 0 0 PAMELA KARSEN 207310 0 83346 0 8172 0 0 0 12205 0 311033 0 0 0 PART I, LINE 1A TAX INDEMNIFICATION AND GROSS-UP PAYMENTS IU HEALTH GOSHEN HOSPITAL GROSSED UP THE TAXABLE VALUE OF AUTOMOBILES FOR 4 OF THE OFFICERS LISTED IN FORM 990, PART VII AND INCLUDED THE AMOUNT IN THE EMPLOYEES' W-2 AS ADDITIONAL COMPENSATION. HEALTH OR SOCIAL CLUB DUES IU HEALTH GOSHEN HOSPITAL PAID FOR COUNTRY CLUB DUES FOR 7 OF THE OFFICERS, KEY EMPLOYEES, AND HIGHEST COMPENSATED EMPLOYEES LISTED IN FORM 990, PART VII. ALL REIMBURSEMENTS ARE CONSIDERED TAXABLE INCOME TO THE EMPLOYEES. PART I, LINE 4B THE FOLLOWING INDIVIDUALS RECEIVED CONTRIBUTIONS TO A NON-QUALIFIED DEFERRED COMPENSATION PLAN: RANDY CHRISTOPHEL - 27,838 JAMES DAGUE - 103,389 AMY FLORIA - 20,071 ALAN WELDY - 24,685 RANDY CAMMENGA - 24,765 PAMELA KARSEN - 16,401 FORM 990, PART VI, SECTION A, LINE 2 THE FOLLOWING OFFICERS, BOARD MEMBERS, AND KEY EMPLOYEES ARE EMPLOYEES OF IU HEALTH GOSHEN OR ITS RELATED ORGANIZATIONS, AND SERVE ON OTHER RELATED IU HEALTH GOSHEN BOARDS: JAMES DAGUE EDWARD BOYTS, MD AMY FLORIA RANDY CHRISTOPHEL ALAN WELDY DAVID KORONKIEWICZ, DO FORM 990, PART VI, SECTION A, LINE 6 IU HEALTH GOSHEN IS THE SOLE MEMBER OF IU HEALTH GOSHEN HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7A IU HEALTH GOSHEN AS THE SOLE MEMBER OF IU HEALTH GOSHEN HOSPITAL HAS THE ABILITY TO ELECT MEMBERS TO THE GOVERNING BODY OF THE HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7B ITEMS THAT REQUIRE APPROVAL OF IU HEALTH GOSHEN INCLUDE ANY AMENDMENT OF THE OPERATING AGREEMENT, DISSOLUTION OF THE ORGANIZATION OR THE SALE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS AND THE AUDIT COMMITTEE IN OCTOBER FOR REVIEW AND QUESTIONS BEFORE THE RETURN IS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C EACH BOARD MEMBER COMPLETES AN ANNUAL DISCLOSURE OF KNOWN OR POTENTIAL CONFLICTS. THE DISCLOSURE ARE REVIEWED BY THE VP-LEGAL. ADDITIONALLY WHEN AGENDA ITEMS ARE DISCUSSED AT MEETINGS IT IS ASKED IF THERE ARE ANY KNOWN OR POTENTIAL CONFLICTS OF INTEREST, AND CONFLICTED PARTIES MUST RECUSE THEMSELVES. FORM 990, PART VI, SECTION B, LINE 15 AN INDEPENDENT COMMITTEE APPROVES THE COMPENSATION WHICH IS DETERMINED TO BE REASONABLE BASED UPON INDEPENDENT COMPARABILITY DATA PROVIDED BY AN INDEPENDENT CONSULTANT. APPROVAL OF AMOUNTS ARE DOCUMENTED IN THE MINUTES. FORM 990, PART VI, SECTION C, LINE 19 IU HEALTH GOSHEN HOSPITAL WILL PROVIDE ANY DOCUMENTS OPEN TO PUBLIC INSPECTION UPON REQUEST. AVERAGE HOURS PER WEEK DEVOTED TO RELATED ORGANIZATIONS: FORM 990, PART VII: EDWARD BOYTS, MD - 40 HOURS DANIEL BRUETMAN, MD - 40 HOURS DAVID KORONKIEWICZ, DO - 40 HOURS DAN BERGER, MD - 40 HOURS CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -6,702,104. EQUITY TRANSFERS 332,662. INTEREST RATE SWAP -173,953. TOTAL TO FORM 990, PART XI, LINE 5: -6,543,395. 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