2011-05-16T09:44:59-05:00 2010-06-30 EIDE BAILLY LLP 401N 31ST ST SUITE 1120 PO BOX 7112 BILLINGS MT 591037112 990 2009-07-01 810231787 Northern Montana Hospital NORT 4062652211 PO Box 1231 Havre MT 595011231 David Henry 4062652211 2011-05-13 1 Client Inactive 4068962400 2009 2016-02-24 21:20:13Z David Henry PO Box 1231 Havre MT 595011231 57693870 0 X www.nmhcare.org X 1921 MT Provision of Healthcare Services 11 5 786 150 324272 -27890 324923 371041 56387131 52416962 968419 452871 10833 12056 57691306 53252930 520062 8909 0 28511711 28161270 0 0 26632845 23362441 55664618 51532620 2026688 1720310 47366467 50643440 9872232 11345455 37494235 39297985 To deliver high quality comprehensive health care services to the hi-line communities. 0 0 38991722 70062 52092690 Northern Montana Hospital (Hospital) provides quality health care regardless of race, creed, sex, national origin, handicap, age, or ability to pay. Although reimbursement for services rendered is critical to the operation of the Hospital, it is recognized that not all individuals possess the ability to purchase these essential services. It is the Hospital's mission to serve the surrounding area by providing healthcare services and healthcare education to all community members. During the year ended June 30, 2010, the Hospital provided $1,245,350 of medical services, based on charges, to individuals who were determined unable to purchase such services under the Hospital's charity care policy and guidelines. In addition to free care and/or subsidized care, care is also provided at below cost rates to persons covered by governmental programs. Recognizing its mission to the community, services are provided to both Medicare and Medicaid patients. The unreimbursed value of providing care to these patients was $25,848,573 for the year ended June 30, 2010. During the fiscal year ended June 30, 2010 the Hospital provided over 5,000 days of hospital services. The nursing home provided over 37,000 days of resident services during the year.The Hospital also provides community care and services through many health care activities and programs provided to support the community. These activities include: wellness programs, community education programs, senior services, health care screening, special programs for specific groups, published articles, radio programs, and a variety of community supported activities. The Hospital also received many hours of volunteer help from the community residents. 38991722 1 1 0 0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 1 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 1 99 0 1 786 1 1 1 0 0 0 0 0 0 0 0 11 5 0 1 0 0 1 0 1 1 0 0 0 1 1 1 1 1 1 1 0 0 X Kim Lucke VP of Finance 4062652211 PO BOX 1231 30 13th st Havre MT 59501 DAVID C HENRY 40.00 X X 354000 0 0 ALAN PEARSON 1.00 X X 0 0 0 JUDY GREENWOOD 1.00 X X 0 0 0 MILES HAMILTON 1.00 X X 0 0 0 Bruce Richardson MD 40.00 X X 323253 0 14671 Paul Tuss 1.00 X 0 0 0 DAVID LEEDS 1.00 X 0 0 0 TOM PATRICK 1.00 X 0 0 0 SUZANNE SWIETNICKI MD 40.00 X 244919 0 19755 JOSEPH MARINO DPM 40.00 X 170808 0 16908 Michael Nolan MD 40.00 X 259844 0 3748 Mike Inman 1.00 X 0 0 0 KAREN POLLINGTON 40.00 X 87786 0 16960 Kim Lucke 40.00 X 69499 0 12838 Shahriar Anoushfar MD 40.00 X 496422 0 3662 Karen E Lien MD 40.00 X 389226 0 23719 John True MD 40.00 X 352286 0 3068 Margaret Dow 40.00 X 210678 0 17717 Stephen Bechdolt 40.00 X 211488 0 9607 3170209 0 142653 25 0 1 1 SLETTEN CONSTRUCTION CO 1000 25TH ST N GREAT FALLS MT 59405 CONSTRUCTION SERVICES 758244 Philips Medical Systems 22100 Bothell Everett Highway Bothell WA 98041 Maintenance Services 398543 DANIEL ABBOTT 1715 13TH STREET WEST HAVRE MT 59501 ANESTHESIA SERVICES 390260 MARk A Ward DO 120 W 30th Street Havre MT 59501 CONTRACT PHYSICIAN SERVICES 335349 HEALTHCARE STAFFING NETWORK LLC PO Box 5413 Englewood CO 80111 CONTRACT STAFFING 334673 17 304446 42020 24575 4446 371041 NET PATIENT SERVICE RE 622110 45400110 45400110 Pharmacy 446110 6303347 5979075 324272 HEALTHCARE CONSULTING 541900 410989 410989 Cafeteria Revenue 722210 224666 224666 Other Program Revenue 900099 77850 77850 52416962 826461 826461 10856 1200 10856 1200 12056 12056 4066350 1000 4440940 -374590 1000 -373590 -373590 53252930 52092690 324272 464927 8909 8909 1459975 1309985 149990 22276217 15593352 6682865 731223 507627 223596 1534204 843812 690392 2159651 1511756 647895 273000 54600 218400 89093 89093 61190 61190 3753258 3523568 229690 321840 321840 7146013 6074111 1071902 393142 314514 78628 1745696 1221987 523709 224897 78714 146183 1958490 1370943 587547 1366277 1093022 273255 BAD DEBT EXPENSE 3766939 3766939 Equipment Rental and Ma 845193 464856 380337 Bed Tax 632718 632718 RECRUITMENT 394708 355237 39471 Collection Fees 233843 233843 156144 31229 124915 51532620 38991722 12540898 0 4115531 4475278 3273317 936844 10380039 10620214 1348870 1378066 391644 391380 45051102 35977156 9085715 9073946 15003659 20135368 3534889 3327184 232803 305160 47366467 50643440 4589775 4392924 5282457 6952531 9872232 11345455 X 37494235 39297985 37494235 39297985 47366467 50643440 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 33189 85804 88331 30662 0 75272 75272 19696099 15257467 4438632 24190256 20085557 4104699 1089475 634132 455343 9073946 Certificate Of Deposit 3239690 F Interest receivable 87494 F 3327184 LIABILITY FOR PENSION BENEFITS 6952531 6952531 53252930 51532620 1720310 1849307 -1765867 83440 1803750 55102237 1849307 1849307 53252930 0 53252930 51532620 0 51532620 0 51532620 Part IV, Line 1b: The custodial funds are not reported on the balance sheet of NMH as they are the personal resource funds of the residents to be used only for their personal needs. If the resident passes, the funds either go to the family or back to the state. They are in no way an asset of the organization. Part X: Description of Uncertain Tax Positions Under FIN 48: The Organization undergoes an annual analysis of its various tax positions, assessing the likelihood of those positions being upheld upon examination with relevant tax authorities. As of June 30, 2010 and 2009, the unrecognized tax benefit accrual is zero. Part XI, Line 8 - Other Adjustments: Minimum Pension Liability Adjustment: -1265867. Equity transfer to related organization: -500000. 1 1 X 1 X 1 X 1 1 0 1 1 2287 698516 698516 0.01460 9940578 9969055 -28477 0.00000 2287 10639094 9969055 670039 0.01460 64131 64131 0.00130 50682 50682 0.00110 8377451 5646072 2731379 0.05720 68129 68129 0.00140 8560393 5646072 2914321 0.06100 2287 19199487 15615127 3584360 0.07560 89868 89868 0.00190 2434 2434 0.00010 4249 4249 0.00010 96551 96551 0.00210 0 2112876 33998 7629163 7874747 -245584 X 0 Northern Montana Hospital

30 13th Street Havre MT 59501

X X X Northern Montana Medical Group West

20 13th Street W Havre MT 59501

Clinic Northern Montana Medical Group East

124 13th Street Havre MT 59501

Clinic Northern Montana Care Center

24 13th Street Havre MT 59501

Nursing Home Part I, Line 6a: The organization's community benefit report was published as a 1/2 page ad in the local newspaper. In addition, a statement about the amount of community benefit the organization provided can be found on their web-site at www.nmhcare.org. Part I, Line 7: Charity care and unreimbursed medicaid was converted to cost using an overall cost to charge ratio. Other Benefits reported in lines e, f and i are actual costs reported in the general ledger. Subsidized health services were calculated using department reports noting actual revenue less medicaid portion already included as community benefit and direct expenses. The calculation also includes an overhead allocation of expenses using the Medicare cost report method of allocating overhead expenses. Part I, Line 7f: The amount of bad debt expense removed from the denominator of the calculation was $3,766,939. Part III, Line 4: Bad debt expense was converted to cost using an overall cost to charge ratio.The estimated amount of bad debt expense attributable to patients eligible under the organization's charity care policy is calculated by using charity care as a percentage of gross patient service revenue. As a portion of revenue is considered charity care, it is assumed that a percentage of bad debt expense would also be considered charity care.Bad debt expense is reported net of discounts and contractual allowances. A payment on an account previously written off reduces bad debt expense in the current year. The carrying amount of patient and resident receivables is reduced by a valuation allowance that reflects management's best estimate of amounts that will not be collected from patients, residents and third-party payors. Management reviews patient and resident receivables by payor class and applies percentages to determine estimated amounts that will not be collected from third parties under contractual agreements and amounts that will not be collected from patients due to bad debts. Management considers historical write off and recovery information in determining the estimated bad debt provision. Part III, Line 8: These expenses represent an overall shortfall of the Medicare patient population. The costs themselves are therefore a community benefit as the community would not receive these services if we did not provide them. Medicare allowable costs of care are based on the Medicare Cost Report. The Medicare Cost Report is completed based on the rules and regulations set forth by CMS. Part VI, Line 2: Community needs assessments are conducted throughout the community by organizations such as HRDC, the Boys & Girls Club and the Montana Economic Development Council. These assessments are shared with the community. Through these assessments, Northern Montana Hospital is able to identify the needs we can help meet. These are: transportation, mental health and youth in need. Northern Montana Hospital has key employees that are working with a collective community group on the transportation coalition. We also participate in a community program, 'Healthy Youth, Healthy Community' in coalition with the Boys & Girls Club and other community organizations. Northern Montana Hospital is helping to meet the mental health needs of the community by offering and subsidizing mental health services. We also subsidize the Bullhook Community Health Center which was formed to meet the needs of the uninsured and underinsured.Beginning in FY 2011 Northern Montana Hospital became a member of the Hill County Health Consortium. The Consortium is composed of many important stakeholders in our community who have joined together. Working together, the consortium members contributed a great deal of time and resource to complete the Community Health Needs Assessment. The CHANGE (Community Health Assessment and Group Evaluation) Tool from the CDC website was chosen to help us through the process of our Community Health Assessment mainly because it would walk us through each step in the process. CHANGE can be used to gain a picture of the policy, systems, and environmental change strategies currently in place throughout the community; develop a community action plan for improving policies, systems, and the environment to support healthy lifestyles; and assist with prioritizing community needs and allocating available resources. The CHANGE Tool involves dividing our community into 5 different sectors and choosing a few sites within those sectors to collect responses from. The 5 Sectors include:(1) Community-At-Large(2) Community-Institutions-Organizations(3) Worksite(4) Health Care(5) SchoolsAlong with the CHANGE Tool, a written survey was created using an example from Wilkes Healthy Carolinians Council. (WilkesHealth.com) This survey seemed to fit closely with our needs, with only minor adjustments being made to fit Hill County. This written survey was available throughout Hill County at various waiting areas so people would have adequate time to complete them. Part VI, Line 3: Northern Montana Hospital informs and educates patients about their eligibility for assistance through a sign posted at our admissions desk, noted in the brochure we give patients at our clinics, and signs posted at our clinic registration desks. In addition, our collection staff always offers charity care as an option when they are discussing the patient's balance with them and also discusses with the patient the availability of various government benefits, such as Medicaid or state programs. As of Oct 2010, NMH has contracted with a company to assist the patient with qualification for programs such as Medicaid and disability determination.We also publish a community benefit report annually which states how much charity care we have given away, and as of recently, we also post our community benefit report on our website and note that we provide charity care. Part VI, Line 4: Northern Montana Hospital is a 49 bed Hospital including 5 swing beds, 5 bed Intensive Care Unit, Emergency Room, Same Day Surgery, and a 6 chair Dialysis Unit; Northern Montana Care Center, a 136 bed Skilled and Intermediate Care Facility - 20 beds of which are designated for resident's with Alzheimer's disease and other related dementias; Northern Montana Assisted Living, a 10 bed facility; Northern Montana Medical Group - East, a Rural Health Clinic; Northern Montana Medical Group - West, a Rural Health Clinic; Northern Montana Vision Center, an Ophthalmology Office; Northern Montana Home Health Care, Northern Montana Home Medical Equipment, Bear Paw Hospice, and the Hi-Line Sleep Center. The hospital's service area consists of Hill, Blaine, Liberty, Philips and the Big Sandy census district of Choteau counties. The population of this service area is approximately 30,000. The median household income is about $37,000. Approximately 45% of the population has a household income below 200% of the Federal Poverty Guidelines. Approximately 22% of the population is covered by Medicaid, 30% by Medicare, 2.41% by CHIP and about 10% uninsured. Additionally, another 5% of the population is covered by Indian Health Service. The entire service area is considered rural and has Health Professional Shortage Area designation for all primary medical care, mental health and dental. In addition, the entire service area is designated as a Medically Underserved Area. Northern Montana Hospital is the only local hospital in its service area, however there are 3 critical access hospitals, 4 rural health clinics, 3 community health clinics and 3 IHS-tribal clinics within its service area. Nearest hospital is critical access and is 35 miles away. Part VI, Line 5: Reported under community building activities is the maintenance of our fitness park. It is a 7 acre park with concrete walking trails, a softball and soccer field. It is a place for the community to get outdoors and exercise. Also included is storage of basketball hoops for the 3-on-3 tournaments the city puts on to get youth out and active. Many leaders of the organization serve on various boards throughout the community, such as the Chamber of Commerce, Hill County Planning Board and Hill County Health Consortium. Through these services, we are able to keep abreast of healthcare needs in the community and collaborate with various organizations to help make it happen. Part VI, Line 6: Northern Montana Hospital extends medical staff privileges to all qualified physicians in its community. The organization applies surplus funds to improvements in patient care by keeping its medical equipment up to date, sending its employed physicians for further continuing education, supporting nursing education through a loan re-payment assistance program and supporting health care education through an education assistance program. In addition, the hospital subsidizes its emergency department by offering 24/7 emergent care coverage to all, regardless of their ability to pay. Northern Montana Hospital also participates in all government sponsored health programs, such as CHIP, Healthy Montana Kids and the Montana Cervical and Breast Cancer program, where it accepts payments for services at greatly discounted rates. Several members of Northern Montana Hospitals leadership team serve on other community boards, such as: Havre Chamber of Commerce, Hill County Health Consortium, Local Emergency Planning, Fetal/Infant/Child mortality review board, Havre/Hill County Planning board, Hill and Blaine County adult protective services committee, Hill County United Way, HRDC Medical Advisory Board, MSU-N Nursing Advisory board and the Safe Kids Safe Communities committee. Part VI, Line 7: N/A 1 Education Assistance 4 8909 0 FMV Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: The organization provides education assistance to qualified employees. The organization monitors the use of the assistance by disbursing the funds directly to the institution. The organization also provides support to a related tax-exempt organization in support of their exempt purpose. X X X X 0 0 0 1 0 0 0 0 0 DAVID C HENRY 273000 0 81000 0 0 0 0 0 0 0 354000 0 0 0 Bruce Richardson MD 322065 0 0 0 1188 0 0 0 17564 0 340817 0 0 0 SUZANNE SWIETNICKI MD 244505 0 0 0 414 0 0 0 22000 0 266919 0 0 0 JOSEPH MARINO DPM 170359 0 0 0 449 0 0 0 18477 0 189285 0 0 0 Michael Nolan MD 258656 0 0 0 1188 0 0 0 6042 0 265886 0 0 0 Shahriar Anoushfar MD 462005 0 0 0 34417 0 0 0 3662 0 500084 0 0 0 Karen E Lien MD 389046 0 0 0 180 0 0 0 27265 0 416491 0 0 0 John True MD 350000 0 0 0 2286 0 0 0 3068 0 355354 0 0 0 Margaret Dow 210543 0 0 0 135 0 0 0 19646 0 230324 0 0 0 Stephen Bechdolt 210670 0 0 0 818 0 0 0 11479 0 222967 0 0 0 Part I, Line 5 Five physicians listed in Part VII of the Form 990 are compensated as a percentage of the prior three months' average gross revenue earned for the Hospital by the Physician, with the percentage being based on their specialty. Supplemental Information Part III Schedule J, Part I, line 3: The CEO/President of Northern Montana Hospital is compensated by an unrelated management company, Fundamental Financial Group, for his services provided to Northern Montana Hospital, Northern Montana Health Care Foundation, Inc. and Northern Montana Health Care, Inc. He serves 40 hours per week at the Hospital, two (2) hours per week at the Foundation, and one (1) hour per week at Northern Montana Health Care, Inc. The board works with the unrelated management company to determine the CEO/President compensation using the methods checked in line 3. Patrick Construction Inc Company is owned by a board member 249538 Construction Services 0 Form 990, Part VI, Section A, line 3 The President/CEO of the Hospital is employed by an unrelated management company. Form 990, Part VI, Section A, line 6 The sole member of the organization is Northern Montana Health Care, Inc. Form 990, Part VI, Section A, line 7b The sole member of the Organization shall have such rights and powers as are provided for in the Articles of Incorporation, the Bylaws of the Organization and the laws of the State of Montana, including but not limited to, the exclusive power: (a) to remove any Trustee from any office at any time, with or without cause; (b) to propose and approve (i) a plan of dissolution or liquidation of the Organization or (ii) a plan of merger or consolidation of the Organization with another corporation; (c) to propose and approve amendments to the Articles of Incorporation and or the Bylaws;(d) to adopt any annual or long-term capital or operational budget or any changes therein exceeding $75,000;(e) to authorize the Organization to enter into any contract or engage in any transaction which is not provided for in an annual or long-term capital or operational budget approved by the sole member of the Organization where the amount involved exceeds $50,000;(f) to adopt substantive changes to existing long-term or master institutional plans of the Organization; (g) to authorize the Organization to engage in, or enter into, any transaction providing for the sale, mortgage or other disposition of all or substantially all of the assets of the Organization; (h) to organize or acquire, or authorize the organization or acquisition of, any subsidiary or affiliate of the Organization; (i) to authorize the Organization to enter into any shared service agreement; (j) to approve long-term borrowing of money by the Organization or authorize the Organizatoin to incur indebtedness involving a mortgage or lien on assets; or (k) to approve the trustees or the President of the Organization from a slate prepared by the Nominating Committee of the Organization. Form 990, Part VI, Section A, line 8b No committee has the authority to act on behalf of the board. Form 990, Part VI, Section B, line 11 A draft copy of the Form 990 will be reviewed by the VP of Finance, then submitted via e-mail to the Board of Directors to view before filing. Form 990, Part VI, Section B, line 12c The conflict of interest policy covers all trustees, directors, officers, and key employees. The Board identifies potential conflicts from annual disclosures. Disclosures are reviewed by administration after all are gathered. A second conflict disclosure letter is sent out annually to all current and former officer, directors, trustees, and key employees to ensure all potential conflicts are identified. The results of this disclosure form are reviewed by the VP of Finance. The Board discusses the potential conflicts and determines if voting on related items would be a conflict of interest. If a conflict is determined to exist, the conflicted individual is excluded from voting on the conflicted item. Form 990, Part VI, Section B, line 15a The CEO/President is compensated by an unrelated management company. The Executive Committee of the board meet and review Northern Montana Hospital(NMH)/Northern Montana Health Care, Inc.(NMHC) financial results, CEO's current year priorities, discuss evaluation tools to be used for CEO evaluation, how comparative salaries will be obtained and discuss the history of compensation to the CEO. At a second executive committee meeting they review non-financial activity of NMH/NMHC and the results of the CEO evaluations completed by the board members. Then they review and discuss a compensation comparative summary of Montana CEO's compensation and a Guidestar CEO Compensation Checkpoint that is prepared specifically for NMH. They agree upon a list of the coming year's priorities for the CEO and proposed compensation, with the compensation set by Board Vote. The process was performed during 2010. Form 990, Part VI, Section C, line 19 The organization's governing documents, conflict of interest policy, and financial statements are made available to the public upon request. Form 990, Schedule R, Part V, Line 2 Method for Determing Value of Transactions Between Related Entities: The method used by Northern Montana Hospital for determining the value of transactions being reported between related entities is either the FMV of the property or actual cost. Form 990, Part VII, Section A Percentage of time spent between related organizations: No individuals are compensated for their board service to either organization, only for their service as employees of the hospital. The following individuals spend 2% of their time on NMHC business and 98% of their time on NMH business: -Vice President of NMHC also serves as the VP of NMH. -The Vice Chair of NMHC also serves as the vice chair and an employed physician of NMH. -Three trustees of NMHC also serve as trustees and employed physicians (including the Medical Director and Chief of Staff) of NMH. The following individuals spend 2% of their time on NMHC business and 2% of their time on NMHCF business and 96% of their time on NMH business: -CEO/President of NMHC also serves as the CEO/President of NMH and NMHCF. -VP of Finance of NMHC also serves as the VP of Finance of NMH and NMHCF. The remaining members of the board of trustees spend 50% of their time on NMHC business and 50% of their time on NMH business. None of them are employed by either organization. North Care Corporation 30 13th Street Havre MT 59501 810447638 Supporting Org MT 501(c)(3) Line 3 N/A Northern Montana Health Care Inc PO Box 1231 Havre MT 59501 810428854 Supporting Org MT 501(c)(3) Line 11b, II N/A NOrthern Montana Health Care Foundation Inc PO Box 1231 Havre MT 59501 363464641 Fundraising MT 501(c)(3) Line 7 N/A 0 0 1 0 0 0 0 0 0 1 1 0 1 1 0 1 1 0 Northern Montana Health Care Inc J 867360 Northern Montana Health Care Inc K 278460 Northern Montana Health Care Foundation Inc N 56024 Northern Montana Health Care Inc N 76503 Northern Montana Health Care Inc P 2223721 Northern Montana Health Care Inc Q 500000 Northern Montana Health Care Foundation Inc C 304447