2012-11-15T16:13:24-06:00 2011-12-31 381357951 PLANTE & MORAN PLLC 750 TRADE CENTRE WAY STE 300 PORTAGE MI 49002 990 2011-01-01 382317300 THREE RIVERS HEALTH AUTHORITY THRE 2692781145 701 S HEALTH PARKWAY THREE RIVERS MI 49093 STEVE ANDREWS 2692781145 2012-11-15 1 CAROL LALONDE CPA P00181637 2695674500 2011 2016-02-24 21:20:13Z THREE RIVERS HEALTH STEVE ANDREWS 701 S HEALTH PARKWAY THREE RIVERS MI 49093 49480642 0 X WWW.THREERIVERSHEALTH.ORG X 1979 MI SEE SCHEDULE O. 12 12 545 80 0 0 24001 41182 42072301 49199549 32195 33883 4402093 142166 46530590 49416780 0 0 0 0 22269233 22556189 0 0 0 23904509 25929281 46173742 48485470 356848 931310 22634960 21073896 13934152 11441778 8700808 9632118 THE HOSPITAL'S MISSION IS TO PROVIDE ACCESS TO HIGH QUALITY HEALTHCARE TO OUR COMMUNITY. 0 0 41354727 49199549 GENERAL ACUTE SERVICES FOR COMMUNITY INPATIENT AND OUTPATIENT SERVICES. 41354727 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 1 0 0 1 38 0 1 545 1 0 0 0 0 0 0 0 0 0 0 X 12 12 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 MI X STEVEN T ANDREWS 2692739604 701 S HEALTH PARKWAY THREE RIVERS MI 49093 X LAURIE HINES 3.00 X X 0 0 0 KEN WIENCEK DO 3.00 X X 0 495130 24135 ANDY GOLDBERGER 3.00 X 0 0 0 DIANA DEGRAAF 3.00 X 0 0 0 PAT HENDERSON 3.00 X 0 0 0 LARRY HERMEN 3.00 X X 0 0 0 GARRETT HALL 3.00 X 0 0 0 RAY BENDURE 3.00 X 0 0 0 JOHN TOUSE 3.00 X 0 0 0 LARRY CLARK 3.00 X X 0 0 0 JACKIE BOWEN 3.00 X 0 0 0 HENRI'ETTA TOLBERT 3.00 X 0 0 0 SUE POTTS 3.00 X X 0 0 0 WILLIAM RUSSELL 40.00 X 225416 0 57528 STEVE ANDREWS 40.00 X 159491 0 44051 HOPE BAILEY 40.00 X 121128 0 25884 ALICE MAYER 40.00 X 80569 0 26968 MIKE PULFORD 40.00 X 145433 0 40593 LEONARD DARLING 40.00 X 123795 0 19788 DOUG ZEHNER 40.00 X 111560 0 20446 DENNIS KNOLL 40.00 X 112935 0 16190 1080327 495130 275583 7 0 1 0 BORGESS MEDICAL CENTER 1521 GULL ROAD KALAMAZOO MI 49048 LAB, LAUNDRY, IT SERVICES 1246769 QHR 105 CONTINENTAL PLACE BRENTWOOD TN 37027 MANAGEMENT SERVICES, SALARIES 840008 REHABCARE GROUP PO BOX 502096 ST LOUIS MO 63150 REHAB MANAGEMENT 317461 OPTIMUM OUTCOMES 4524 SOUTHLAKE PKWY HOOVER AL 35744 PATIENT COLLECTION SERVICES 304909 ECLIPSE CAPITAL 2207 ORCHARD LAKE RD SYLVAN LAKE MI 48320 FINANCIAL CONSULTING 205319 11 41182 41182 NET PATIENT REVENUE 621110 43922815 43922815 OTHER PROGRAM REVENUE 621110 5276734 5276734 49199549 32973 32973 132747 63862 68885 68885 68885 910 0 910 910 910 CAFETERIA/VENDING 900099 47571 47571 MISCELLANEOUS 900099 25710 25710 73281 49416780 49199549 0 176049 770065 770065 16504207 14071990 2432217 185419 166877 18542 3762274 3386047 376227 1334224 1200802 133422 255622 255622 194679 194679 96126 96126 4995 4995 139996 139996 6979902 5152598 1827304 18721 18721 272930 272930 2242679 2242679 174929 174929 317921 317921 2574659 2574659 765432 54448 710984 MEDICAL SUPPLIES 5665906 5519709 146197 PHYSICIAN FEES 3947582 3947582 EQUIP RENTAL AND MAINT 1824242 1421367 402875 PROF DUES & DEVELOPMENT 103110 103110 349850 314865 34985 48485470 41354727 7130743 0 616145 499662 5219411 5023368 574851 621088 821087 1138798 47808782 36219748 13593905 11589034 891330 668392 918231 1533554 22634960 21073896 6641078 6133351 3498747 201000 3463416 2037160 2000000 330911 1070267 13934152 11441778 X 0 0 0 0 8700808 9632118 8700808 9632118 22634960 21073896 931310 0 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 4995 4995 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: A PORTION OF MHA DUES IS ALLOCATED TO LOBBYING EXPENSE. 219500 219500 20567204 13329905 7237299 27022078 22889843 4132235 11589034 COST REPORT SETTLEMENTS 1523169 BOND FEES NET OF AMORTIZATION 10385 1533554 COST REPORT SETTLEMENTS PAYABLE 1070267 1070267 49416780 48485470 931310 931310 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL, TRAH PROPERTIES, AND THREE RIVERS HEALTH FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. IHS AND PHO ARE DEEMED A CORPORATIONS AND FILE 1120S WITH NO TAX DUE. THE HOSPITAL'S TAX RETURNS ARE NOT SUBJECT TO EXAMINATION BY TAXING AUTHORITIES FOR YEARS BEGINNING PRIOR TO DECEMBER 31, 2008. THE HOSPITAL HAS ADOPTED ACCOUNTING STANDARDS RELATED TO UNCERTAIN TAX POSITIONS AND, ACCORDINGLY, REVIEWED ALL TAX POSITIONS. THE EVALUATED POTENTIAL EXPOSURE RELATED TO UNCERTAIN TAX POSITIONS WAS FOUND TO BE IMMATERIAL. 1 1 1 X 250.000000000000 1 X 1 1 1 0 0 280721 280721 0.00580 11881766 7904275 3977491 0.08200 1008648 232241 776407 0.01600 13171135 8136516 5034619 0.10380 93798 93798 0.00190 78712 78712 0.00160 2937794 4004044 -1066250 0.00000 3110304 4004044 -893740 0.00350 16281439 12140560 4140879 0.10730 88452 88452 0.00180 88452 88452 0.00180 0 8451890 752473 10647517 12259097 -1611580 X 1 1 1 1 THREE RIVERS HEALTH

701 S HEALTH PARKWAY THREE RIVERS MI 49093

X X X THREE RIVERS HEALTH 1 0 1 1 250.000000000000 1 250.000000000000 0 1 1 X X X X 1 0 1 X 0 1 3 THREE RIVERS HEALTH FAMILY CARE

677 E MAIN STREET PO BOX 310 CENTREVILLE MI 49032

RURAL HEALTH CLINIC - CENTREVILLE THREE RIVERS HEALTH FAMILY CARE

721 6TH AVENUE STE B THREE RIVERS MI 49093

RURAL HEALTH CLINIC - THREE RIVERS THREE RIVERS HEALTH FAMILY CARE

119 S KALAMAZOO STREET PO BOX 295 CENTREVILLE MI 49032

RURAL HEALTH CLINIC -WHITE PIGEON PART I, LINE 7: COSTING METHODOLOGY IS A COST TO CHARGE RATIO AS DEFINED BY THE IRS INSTRUCTIONS. PART II: WE CONTINUE TO INVEST IN PHYSICIAN RECRUITING INITIATIVES, TO ENSURE THAT WE HAVE ADEQUATE PROVIDERS TO MEET THE ACCESS NEED IN ST. JOE COUNTY. PART III, LINE 4: THE HOSPITAL HAS AGREEMENTS WITH THIRD-PARTY PAYORS THAT PROVIDE FOR PAYMENTS TO THE HOSPITAL AT AMOUNTS DIFFERENT FROM ITS ESTABLISHED RATES. PAYMENT ARRANGEMENTS INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE, REIMBURSED COSTS, DISCOUNTED CHARGES, AND PER DIEM PAYMENTS. NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZED AMOUNTS FROM PATIENTS, THIRD-PARTY PAYORS, AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYORS. RETROACTIVELY CALCULATED ADJUSTMENTS ARISING UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARY PAYORS ARE ACCRUED ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED AND ADJUSTED IN FUTURE PERIODS, AS FINAL SETTLEMENTS ARE DETERMINED.LAWS AND REGULATIONS GOVERNING THE MEDICARE AND MEDICAID PROGRAMS ARE COMPLEX AND SUBJECT TO INTERPRETATION. MANAGEMENT BELIEVES THAT IT IS IN COMPLIANCE WITH ALL APPLICABLE LAWS AND REGULATIONS. FINAL DETERMINATION OF COMPLIANCE OF SUCH LAWS AND REGULATIONS IS SUBJECT TO FUTURE GOVERNMENT REVIEW AND INTERPRETATION. VIOLATIONS MAY RESULT IN SIGNIFICANT REGULATORY ACTION INCLUDING FINES, PENALTIES, AND EXCLUSION FROM THE MEDICARE AND MEDICAID PROGRAMS.BAD DEBT EXPENSES IS TYPICALLY DOLLARS THAT ARE WRITTEN OFF OR RESERVED FOR THAT PERTAINS TO PATIENTS THAT HAD AVAILABLE RESOURCES, BUT WOULD NOT PAY FOR THEIR SERVICES. THE EXCEPTION TO THIS RULE APPLIES TO CHARITY CARE ACCOUNTS THAT ACTUALLY ARE INCLUDED IN BAD DEBT BECAUSE OF LACK OF INFORMATION PROVIDED, OR BECAUSE OF THE TIMING OF DETERMINTATION FOR CHARITY CARE. WE ESTIMATE THAT AT THE END OF 2011, APPROXIMATELY $1,000,000 DOLLARS INCLUDED IN BAD DEBT SHOULD ACTAULLY BE CONSIDERED CHARITY CARE. BECAUSE OF THIS WE BELIEVE THIS SHOULD ALSO BE INCLUDED IN OUR COMMUNITY BENEFIT CALCULATION. PART III, LINE 8: THE SHORTFALL SHOULD BE CONSIDERED A COMMUNITY BENEFIT. MANY OF THESE PATIENTS HAVE LIMITED INCOME WHICH IN MOST CASES IS FIXED. THE COST TO CHARGE RATIO WAS USED TO DETERMINE COSTS. WITH MEDICARE BEING OUR LARGEST POPULATION OF PATIENTS, THE MEDICARE SHORTFALL IS ENORMOUS, THUS SHOULD BE TREATED AS A SIGNIFICANT COMMUNITY BENEFIT. PART III, LINE 9B: THE HOSPITAL CURRENT COLLECTION PRACTICES APPLY TO ALL PATIENTS. IF NO INSURANCE IS AVAILABLE, AND THEY DO NOT QUALFY FOR CHARITY CARE, WE THEN MAKE THEM AWARE OF THEIR OPTIONS. DISCOUNTS ARE OFFERED, WHICH ARE BASED ON OUR DISCOUNTS GIVEN TO COMMERCIAL PAYORS. PAYMENT ARRANGEMENTS CAN BE MADE THAT COVER A SPECIFIC PERIOD OF TIME. ONCE ARRANGEMENTS ARE MADE, THE COLLECTION PROCESS FOLLOWS THE STANDARD OF COLLECTION NOTICES, AND PHONE CALLS. AFTER 120 DAYS, IF NO PAYMENT HAS BEEN MADE, OR IF PAYMENT ARRANGEMENTS ARE NOT KEPT, THE BALANCES WILL BE REFERRED TO A COLLECTION AGENCY. THREE RIVERS HEALTH PART V, SECTION B, LINE 21: ALL PATIENTS ARE BILLED THE INITIAL CHARGES, THUS, IF THEY QUALIFY FOR ASSISTANCE, THE FULL AMOUNT WILL BE WRITTEN OFF. FOR PATIENTS THAT HAVE NO INSURANCE BUT DO NOT QUALIFY FOR ASSISTANCE, SOME WILL STILL QUALIFY FOR DISCOUNTS BASED ON TIMING OF PAYMENT OR PAYMENT PLANS. PART VI, LINE 2: THE ORGANIZATION CURRENTLY REVIEWS THE HEALTH INDICATORS OF THE COUNTY, AND ALSO FROM TIME TO TIME COMPLETES COMMUNITY SURVEYS. WE ALSO DO PHYSICIAN DEMAND REVIEWS TO DETERMINE IF THERE ARE PHYSICIAN SHORTAGES IN OUR COMMUNITY. WE ALSO REVIEW BY SERVICE AND PATIENT TYPE, TO SEE IF THERE ARE ANY TRENDS THAT INDICATE CHANGES IN UTILIZATION AT THE HOSPITAL. WE ALSO PARTNER WITH THE SCHOOLS, AND COMMUNITY MENTAL HEALTH, TO IDENTIFY ANY INITIATIVES THAT WOULD BENEFIT THE COMMUNITY. WE ALSO HAVE AN EXTENSIVE PATIENT SATISFACTION PROGRAM THAT IDNETIFIES POTENTIAL GAPS IN COMMUNITY SERVICE. PART VI, LINE 3: ONCE WE IDENTIFY A PATIENT WHO HAS NO COVERAGE, WE SEND THEM TO OUR PATIENT ASSISTANCE REPRESENATIVE. THIS REPRESENATIVE WILL THAN GO OVER ALL THE OPTIONS THAT ARE AVAILABLE FOR THAT INDIVIDUAL. IF MEDICAID IS A POSSIBILITY, WE THEN SEND THIS PERSON TO OUR MEDICAID SPECIALIST, WHO WILL HELP THEM WITH THE PROCESS,AS WELL AS ANY FORMS. WE HAVE A FORMAL CHARITY CARE PROGRAM, WHICH IS ADVERTISED HOSPITAL WIDE, AND ON OUR WEBSITE. IF THEY QUALIFY FOR CHARITY CARE, WE WILL EDUCATE THEM AS ASSIST THEM WITH THE PAPERWORK AND PROCESS. PART VI, LINE 4: THE HOSPITAL PRESENTLY HELPS SERVE ST. JOE COUNTY ALONG WITH OTHER PROVIDERS IN THE COMMUNITY. THE POPULATION OF THIS COMMUNITY IS APPROXIMATELY 63,000. THE COMMUNITY IS PRESENTLY ECONOMICALLY DEPRESSED. IT WAS AN AREA THAT WAS HEAVILY DEPENDENT ON THE AUTO INDUSTRY. THE UNEMPLOYMENT RATE IS VERY HIGH, AND THE COUNTY HAS A VERY HIGH MEDICAID POPULATION. IN ADDITON, THE NUMBER OF PEOPLE WITHOUT HEALTH INSURANCE HAS ALSO INCREASED IN THE PAST FEW YEARS. IT IS CLASSIFIED AS A RURAL AREA IN THE MIDWEST, THOUGH IT IS CLOSE TO URBAN AREAS. PART VI, LINE 5: THE HOSPITAL OWNS AND OPERATES A 32,000 SQUARE FOOT WELLNESS CENTER, WHICH PROVIDES MEMBERSHIP OPTIONS TO THE PUBLIC, HEALTH ASSESSMENTS, DIABETIC EDUCATION, DIET PLANS, OP PHYSICAL THERAPY, AND CARDIAC REHAB. THIS WELLNESS CENTER PROVIDES MEMBERSHIPS AT A REDUCED RATE, AND DOES NOT MAKE A PROFIT ON THE MEMBERSHIPS. WE PROMOTE HEALTH BY IMPROVING ACCESS TO CARE BY INVESTING IN THREE RURAL HEALTH CLINICS, WITH TWO OF THOSE CLINICS BEING OFF THE HOSPITAL CAMPUS. REPORTS FILED WITH STATES PART VI, LINE 7 MI 1 X X X 0 0 0 0 0 0 0 0 0 KEN WIENCEK DO 0 489380 0 5750 0 0 0 0 0 24135 0 519265 0 0 WILLIAM RUSSELL 213996 0 0 0 11420 0 0 0 57528 0 282944 0 0 0 STEVE ANDREWS 148665 0 0 0 10826 0 3195 0 40856 0 203542 0 0 0 MIKE PULFORD 142683 0 2750 0 0 0 20536 0 20057 0 186026 0 0 0 ORGANIZATION MISSION STATEMENT FORM 990, PART I, LINE 1: THE HOSPITAL'S MISSION IS TO PROVIDE ACCESS TO HIGH QUALITY HEALTHCARE TO OUR COMMUNITY. WE SERVE A COMMUNITY THAT HAS ONE OF THE HIGHEST UNEMPLOYMENT RATES IN THE STATE. WE EMPLOY 90% OF THE PHYSICIANS IN THE COMMUNITY, THUS PROVIDING ADEQUATE ACCESS TO OUR COMMUNITY, SPECIFICALLLY MEDICAID ELGIBLE PATIENTS. WE OPERATE 3 RURAL HEALTH CLINICS, AND WILL HAVE ONE MORE OPERATIONAL IN 2012, WHICH GREATLY ENHANCES ACCESS TO CARE. WE PROVIDE A FULL RANGE OF OB SERVICES TO THE COMMUNITY, OF WHICH OVER 60% IS MEDICAID. WE ALSO PROVIDE WELLNESS AND DIABETIC EDUCATION SERVICES TO THE COMMUNITY, AS WELL AS HOMECARE AND HOSPICE, ALL SERVICES THAT ARE HEAVILY SUBSIDIZED. IN ADDITION, THE HOSPITAL ALSO HAS A IP REHABILITATION UNIT ON CAMPUS AS WELL. WE HAVE STARTED AN EMPLOYEE WELLNESS PROGRAM INTERNALLY, AND PLAN TO WORK WITH LOCAL EMPLOYERS TO OFFER THIS SERVICE AS WELL. FUTURE PLANS INCLUDE OFFERING MENTAL HEALTH SERVICES, AND WOUND CARE SERVICES TO THE COMMUNITY. ADDITIONALLY, WE ARE ADDING RESOURCES TO HELP THE UNINSURED NAVIGATE THE REQUIREMENTS FOR OBTAINING INSURANCE COVERAGE FOR THEIR PROBLEMS. FORM 990, PART VI, SECTION A, LINE 3 THE HOSPITAL USES A MANAGEMENT COMPANY TO MANAGE OPERATIONS. THEY ALSO EMPLOY THE CEO AND CFO. FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS PRESENTED AT THE BOARD MEETING, AND REVIEWED BY OFFICERS AND MEMBERS DURING THE MEETING AFTER THE RETURN IS FILED. FORM 990, PART VI, SECTION B, LINE 12C THE COMPLIANCE OFFICE REQUIRES ANNUAL DISCLOSURE, AND COMMUNICATES TO BOARD PERIODICALLY. IF A CONFLICT OF INTEREST ARISES, THE INDIVIDUAL IS REQUIRED TO LEAVE THE ROOM WHEN DISCUSSIONS TAKE PLACE. FORM 990, PART VI, SECTION B, LINE 15 THE HOSPITAL USES DATA FROM MHA TO DETERMINE THE SALARY STRUCTURE FOR EMPLOYEES. FOR THE CEO AND CFO, QHR IS THE PRIMARY SOURCE FOR COMPENSATION, WHICH MUST BE APPROVED BY THE BOARD. THE SALARY PLAN IS PRESENTED TO THE FINANCE COMMITTEE AS WELL. ALL DECISIONS ARE DOCUMENTED IN THE BOARD MINUTES. THE MOST RECENT YEAR THIS PROCESS WAS UNDERTAKEN WAS 2011. FORM 990, PART VI, SECTION C, LINE 19 POLICIES AND STATEMENTS ARE REVIEWED AT BOARD MEETINGS. THE LOCAL PRESS ALSO RECEIVES THIS INFORMATION. IF ADDITIONAL REQUESTS ARE MADE, THIS INFORMATION IS PROVIDED AS REQUESTED. FORM 990, PART VII: STEVE ANDREWS AND WILLIAM RUSSELL EACH WORKED AN AVERAGE OF AT LEAST 6 HOURS PER WEEK AT RELATED ORGANIZATIONS. HOPE BAILEY WORKED AN AVERAGE OF AT LEAST 5 HOURS PER WEEK AT A RELATED ORGANIZATION. LARRY CLARK AND PAT HENDERSON EACH WORKED AN AVERAGE OF AT LEAST 1 HOUR AT A RELATED ORGANIZATION. KEN WIENCEK, DO WORKED AN AVERAGE OF AT LEAST 40 HOURS PER WEEK AT A RELATED ORGANIZATION. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED SINCE THE PRIOR YEAR. THREE RIVERS HEALTH FOUNDATION 701 S HEALTH PARKWAY THREE RIVERS MI 49093 201384776 FOUNDATION TO HOSPITAL MI 501(C)(3) 11 TYPE 1 THREE RIVERS HEALTH AUTHORITY 1 TRAH PROPERTIES INC 701 S HEALTH PARKWAY THREE RIVERS MI 49093 383366344 PROPERTY MANAGEMENT MI 501(C)(3) 11 TYPE 1 THREE RIVERS HEALTH AUTHORITY 1 THREE RIVERS HEALTH NETWORK 701 S HEALTH PARKWAY THREE RIVERS MI 49093 383330974 MEDICAL DATA PROCESSING MI THREE RIVERS HEALTH AUTHORITY C 13840 1.00000 INTEGRATED HEALTH SYSTEMS INC 701 S HEALTH PARKWAY THREE RIVERS MI 49093 383134384 PERSONNEL MANAGEMENT MI N/A C 0 0 0 0 0 0 0 0 0 1 1 0 1 0 1 0 0 0 TRAH PROPERTIES INC J 309139 RENT PAID INTEGRATED HEATH SYSTEMS INC O 4333547 FMV