2011-05-16T10:13:29-05:00 2010-06-30 LARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2009-07-01 810384618 BIG HORN HOSPITAL ASSOCIATION BIGH 4066652310 17 NORTH MILES AVENUE HARDIN MT 59034 Roxie Cain 4066652310 2011-05-13 1 6123764500 2009 2016-02-24 21:20:13Z Terry Bullis 17 NORTH MILES AVENUE HARDIN MT 59034 11347790 0 X BIGHORNHOSPITAL.ORG X 1980 MT Big Horn Hospital Association, along with its affiliated staff, will work together to provide caring, economical, quality medical and health services in Big Horn County and surrounding areas. 7 7 217 12 0 0 198580 299394 9656841 10850331 8429 11229 -5561 17439 9858289 11178393 1000 0 0 5631550 6335983 0 0 4155638 4488399 9788188 10824382 70101 354011 8798202 9305775 2167856 2288607 6630346 7017168 Big Horn Hospital Association, along with its affiliated staff, will work together to provide caring, economical, quality medical and health services in Big Horn County and surrounding areas. 0 0 9661621 10850331 BIG HORN HOSPITAL ASSOCIATION IS COMPRISED OF BIG HORN HOSPITAL AND HERITAGE ACRES. BIG HORN HOSPITAL IS A 25-BED ACUTE CARE HOSPITAL. HERITAGE ACRES IS A 36-BED NURSING CARE FACILITY AND A 10-UNIT ASSISTED LIVING AND 10-UNIT INDEPENDENT LIVING. DURING THE YEAR ENDED JUNE 30, 2010, BIG HORN HOSPITAL PROVIDED 724 DAYS OF PATIENT SERVICES AND 4,012 DAYS OF RESIDENT SERVICES; HERITAGE ACRES PROVIDED 12,158 DAYS OF RESIDENT SERVICES. BIG HORN HOSPITAL ASSOCIATION PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS AT OR BELOW COST AND TO INDIVIDUALS WHO ARE UNABLE TO PAY. THE UNREIMBURSED VALUE OF PROVIDED CARE TO THESE PATIENTS WAS $84,489 FOR THE YEAR ENDED JUNE 30, 2010. 9661621 1 1 0 1 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 27 0 1 217 1 0 0 0 0 0 0 0 0 0 7 7 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 0 1 1 0 0 MT X ROXIE CAIN CONTROLLER 4066652310 17 N MILES AVENUE HARDIN MT 59034 TERRY BULLIS 0.40 X X 0 0 0 C william fisher 0.40 X X 0 0 0 james seykora 0.40 X X 0 0 0 sue murphy 0.40 X X 0 0 0 gary ostahowski md 0.40 X 0 0 0 chad fenner 0.40 X 0 0 0 rocky eggart 0.40 X 0 0 0 gary robertson 40.00 X 125983 0 11761 Roxie Cain 40.00 X 70014 0 13706 CARLA TRAFT 40.00 X 83172 0 2906 WILLIAM HODGES 40.00 X 72024 0 12731 PAULA SMALL-PLENTY 40.00 X 74098 0 14031 Kristi Gatrell 40.00 X 89021 0 7133 Mike Cary 40.00 X 82258 0 14031 195997 0 25467 1 0 0 0 diane fischer - crna pc 4395 highway 87 n billings MT 59105 CRNA 147320 1 157034 94548 47812 299394 Patient Revenue 621110 10784723 10784723 Cafeteria 900099 32893 32893 Other Misc Rev 900099 32715 32715 10850331 12679 12679 170259 152820 17439 17439 17439 15127 16577 -1450 -1450 -1450 11178393 10784723 0 94276 235324 32394 202930 5050481 4695730 354751 82228 72646 9582 604678 536005 68673 363272 343474 19798 1163 1163 50509 50509 1063535 1045338 18197 14641 130 14511 725303 666211 59092 24106 7215 16891 189527 189527 65712 46036 19676 11412 11412 477430 452469 24961 150977 150977 Bad Debt 671408 671408 Equipment Rental and Ma 305144 256679 48465 Food 231653 231653 Bed Taxes 144801 144801 Minor Equipment 137646 119717 17929 223432 150188 73244 10824382 9661621 1162761 0 1277270 1270594 604341 961333 1373516 1402498 57236 78559 137322 173522 113855 99957 14502816 9289033 5212090 5213783 22572 105529 8798202 9305775 1118567 1253226 152000 136000 805000 730000 28894 92289 140487 2167856 2288607 X 6451268 6840034 179078 177134 6630346 7017168 8798202 9305775 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 322 322 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: Portion of dues paid to Montana Hospital Association and the American hospital association that is used for lobbying purposes. 0 1 242904 242904 11454491 7240803 4213688 185747 78506 107241 2498153 1969724 528429 121521 121521 5213783 Part IV, Line 2b: The hospital acts as a custodian for the funds of the nursing home residents. Those funds appear as restricted cash and account payable in the balance sheet. 1 1 1 X 1 X 1 1 0 0 117154 117154 0.01150 1971592 1575517 396075 0.03900 2088746 1575517 513229 0.05050 2088746 1575517 513229 0.05050 1 512550 0 2345171 2819665 -474494 X 1 0 Big Horn Hospital Association

17 N Miles Hardin MT 59034

X X X Heritage Acres

200 North Mitchell Hardin MT 59034

Extended Care Facility (SNF, Assisted Living, and Independent Living) Part I, Line 3c: The "test" for community care is in the form of income, which is verified with the tax returns. If a person meets the 100% of Federal Poverty Guidelines their entire bill is written off except for a $10 co-pay. The organization then provides a sliding fee scale for discounted care up to 200% of the federal poverty guildlines. The Organization provides customers with an application upon request, if the customer is strictly private pay or if we have knowledge of a financial hardship. The Organization keeps a log of community care applications given to customers as well as for community care awarded and denied. Part I, Line 7g: Physician's fees billed from BHHA are written off if a customer is eligible for community care. Part III, Line 4: Part III, Line 4: The following is from the "Patient and Resident Accounts Receivable" paragraph in Note 1 to the Hospital's Financial Statements:"The Hospital reports patient and resident accounts receivable for services rendered at net realizable amounts from third-party payors, patients, residents and others. The Hospital provides and allowance for doubtful accounts based upon a review of outstanding receivables, historical collection information and existing economic conditions. As a service to the patient and resident, the Hospital bills third-party payors directly and bills the patients and resident when the patient and resident's liability is determined. Patient and resident accounts receivable are ordinarily due in full when billed. Delinquent receivables are written off based on individual credit evaluation and specific circumstances of the patient and resident or third-party payor."The amount of bad debt expense (at cost) reports in part III, line 2 is calculated as follows: payment arrangement include prospectively determined rates per discharge, reimbursed costs, discounted charges and per diem payments. Net patient service revenue is reported at the estimated net realizable amounts from patients, third-part payors, and others for services rendered, including estimated retroactive adjustments under reimbursement agreements with third-party payors. Part III, Line 8: Shortfall will be $332,961 of deductable and coinsurance and $141,523 settlement. From Part III, line 6 the total allowable cost reports to medicare was based on the 2010 filed medicare cost report. Part V: 1 hospital and 1 skilled nursing facility. Part VI, Line 2: The Hospital has done a mail survey to help assess the needs of the community. BHHA also uses communication with the physician practice as to what would be useful and needed by their paitient population. Part VI, Line 3: The facility keeps forms on hand that are available (on in plain site) for different gov't programs such as Health MT Kids. The patient accounts representative will inform any private pay patient of our community care and will also relay this information to customers when discussing payment options for outstanding bills. Part VI, Line 4: BHHA servers a high poverty level. They are on the edge of the Crow Indian Reservation and have a lot of customers who utilize Indian Health Services as a payor source for health care. Their population has a large population of Medicare and Medicaid customers. As they serve a small town in Montana, the population consists of a lot of children as well as elderly, both of which utilize our healthcare system. Part VI, Line 5: BHHA uses the local papers as an outlet for giving the public information on different type of health concerns, such as diabetes, weight loss etc. Their public health educatior is developing a health council to help educate and share ideas with other health providers in the community as to the type of services needed in the area and how to get those services to the population. Part VI, Line 6: BHHA does have a community board to help not on "run" the facility with policies and procedures, but to give input to the management team about the needs they see for the community in which they live. BHHA is developing more educational programs for items such as women's health, diabetes managment and smoking cesastion. Form 990, Part VI, Section A, line 1 THE EXECUTIVE COMMITTEE SHALL HAVE ALL OF THE POWERS OF THE BOARD OF DIRECTORS WHEN THE BOARD IS NOT IN SESSION AND SHALL GENERALLY PERFORM SUCH DUTIES AND EXERCISE SUCH POWERS AS MAY BE PERFORMED AND EXERCISED BY THE BOARD OF DIRECTORS FROM TIME TO TIME. Form 990, Part VI, Section B, line 11 990 is reviewed by the Controller and CEO, a copy is not presented to the Board before filing. Form 990, Part VI, Section B, line 12c Regular compliance meetings duscuss any actual conflicts or potential conflicts. There is also a hotline number to call for compliance or HIPAA issues that is operated by MHA, not BHHA. Board members sign yearly conflict of interest statements and if a conflict occurs on a specific item, they abstain from the vote on that item. Form 990, Part VI, Section B, line 15a All positions - MHA salary survey is completed and reviewed every year to allow fair pay for all positions. THE BOARD ALSO REVIEWS AND APPROVES THE CEO'S COMPENSATION AND WAS LAST DONE IN 2010. Form 990, Part VI, Section C, line 19 Governing documents, Conflict of Interest Policy and Financial Statements are made availabe to the public upon request to the business office. Big Horn County Memorial Hospital and Healthcare Foundation 17 N Miles Avenue Hardin MT 59034 810504410 Hospital Fundraising MT 501(c)(3) 11 Type 1 N/A Big Horn County Memorial Hospital Auxiliary HC 36 Box 2065 Hardin MT 59034 810428249 Funds to benefit Big Horn County Memorial Hospital MT 501(c)(3) 11 Type 2 N/A Heritage Acres Auxiliary Limited PO Box 474 Hardin MT 59034 810444017 Funds to benefit Heritage Acres Nursing Home MT 501(c)(3) 11 Type 2 N/A 0 1 1 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0 Big Horn Hospital and Health Care Foundation C 157034