2011-11-15T13:17:59-05:00 2010-12-31 ERNST & YOUNG LLP 111 MONUMENT CIRCLE STE 2600 INDIANAPOLIS IN 46204 990 2010-01-01 351536132 MEMORIAL HEALTH SYSTEM INC MEMO 5746473549 615 N MICHIGAN STREET SOUTH BEND IN 46601 JEFFREY COSTELLO 2011-11-15 3176817000 2010 2016-03-07 17:11:31Z PHILIP NEWBOLD 615 N MICHIGAN STREET SOUTH BEND IN 46601 78719025 false X QUALITYOFLIFE.ORG X 1981 IN MEMORIAL HEALTH SYSTEM, INC. IS COMMITTED TO IMPROVING THE QUALITY OF LIFE OF THE PEOPLE IN OUR COMMUNITY. 13 10 876 0 2311155 0 1791723 1966424 66403457 67793807 -409523 604115 2613431 2403293 70399088 72767639 0 329745 0 0 59284259 60258564 0 0 0 29361381 31507624 88645640 92095933 -18246552 -19328294 100079170 99994316 49049473 46648276 51029697 53346040 X MEMORIAL HEALTH SYSTEM, INC. IS COMMITTED TO IMPROVING THE QUALITY OF LIFE OF THE PEOPLE IN OUR COMMUNITY. false false 54557387 44126035 MEMORIAL HEALTH SYSTEM, INC. (THE "CORPORATION") OPERATES MEMORIAL MEDICAL GROUP. MEMORIAL MEDICAL GROUP IS A PRIMARY CARE NETWORK OF PHYSICIANS AND ALSO INCLUDES THE MED-POINT IMMEDIATE CARE CENTERS AND CENTER FOR OCCUPATIONAL HEALTH. MEMORIAL MEDICAL GROUP (MMG) IS THE OWNED MULTI-SPECIALTY INTERGRATED PHYSICIAN NETWORK OF MEMORIAL HEALTH SYSTEM. IN ADDITION TO THE PHYSICIAN PRACTICES, MMG OPERATES A HIGH COMPLEXITY CORE LABORATORY FOR THE SUPPORT OF ITS EMPLOYED PHYSICIANS. THE CENTER FOR OCCUPATIONAL HEALTH (COH) AND WORKER'S COMPENSATION SERVICES FOR 1500 CLIENT COMPANIES IN ST. JOSEPH AND LAPORTE COUNTIES. MMG ALSO OPERATES MED-POINT URGENT CARE CENTERS TO SUPPLEMENT THE SERVICES OF THE MEDICAL GROUP AND COH. MMG OPERATES MED-POINT EXPRESS, A RETAIL BASED WALK-IN CLINIC AT VARIOUS RETAIL SUPERCENTERS OR GROCERY STORES. IN ADDITION TO THE CORPORATION'S PRIMARY CARE NETWORK, MEMORIAL MEDICAL GROUP MANAGES THE OPERATION OF SEVERAL HOSPITAL BASED PRACTICES FOR THE HOSPITALISTS, TRAUMA ORTHOPEDIC SURGEON, AND PEDIATRIC INTENSIVISTS. 16263312 329745 23394492 MEMORIAL HEALTH SYSTEM, INC. (THE "CORPORATION") WAS ESTABLISHED AS THE PARENT CORPORATION OF MEMORIAL HOSPITAL OF SOUTH BEND, INC. (THE "HOSPITAL") IN 1981 TO DEVELOP A FULL SPECTRUM OF HEALTH-RELATED SERVICES FOR NORTH CENTRAL INDIANA AND SOUTHWESTERN MICHIGAN. THE CORPORATION IS COMMUNITY-OWNED AND NOT-FOR-PROFIT. ALONG WITH ITS SUBSIDIARIES, THE CORPORATION SERVES THE GREATER COMMUNITY THROUGHOUT THE CONTINUM OF CARE FROM HEALTH PROMOTION AND SICKNESS PREVENTION TO DIAGNOSIS, INPATIENT, OUTPATIENT AND HOME CARE SERVICES. IT CONTROLS THE HOSPITAL, MEMORIAL HEALTH FOUNDATION, THE HOSPITAL'S PHILANTHROPIC ARM, AND MEMORIAL HOME CARE, INC., COLLECTIVELY REFERRED TO AS THE "SYSTEM". THE CORPORATION PROVIDES CORPORATE SERVICES TO THE ABOVE MENTIONED AFFILIATED ORGANIZATIONS. ALONG WITH ITS OWN AFFILIATED ORGANIZATIONS, MEMORIAL HEALTH SYSTEM, INC. HAS FORMED SEVERAL JOINT VENTURES WHICH FURTHERS ITS WORK IN THE CONTINUUM OF CARE. 325899 278051 MEMORIAL HEALTH SYSTEM, INC. (THE "CORPORATION") OPERATES MEMORIAL MEDICAL GROUP (MMG). ALONG WITH THE PRIMARY CARE NETWORK, MMG ALSO OPERATES THE MEMORIAL MEDICAL GROUP CLINICAL RESEARCH INSTITUTE (CLINICAL RESEARCH). CLINICAL RESEARCH IS CURRENTLY FOCUSED ON PHARMACOLOGY STUDIES. CLINICAL RESEARCH HAS BROUGHT THE FOLLOWING POSITIVE BENEFITS TO MMG: IMPROVED PATIENT CARE - BRINGS MMG PHYSICIANS AND NURSES CLOSER TO LEADING-EDGE MEDICINE. CORPORATE POSITIONING - CLINICAL RESEARCH CAN ENHANCE MMG'S IDENTITY AND BRAND, IT CAN PROVIDE A MEANS TO MEET PHYSICIANS' ACADEMIC NEEDS AND ENHANCE PHYSICIAN RECRUITMENT. 655622 11562 MANAGED CARE SERVICES 655622 11562 71802220 true true false true false false false false false true false true false true false false true false false false false false false false false true false true true true false false false false false false false true false false false false false true true true false false true 224 0 true 876 true true true false false false false false false false false false X 13 10 true false false false false false false true true false true false true false false false true true true false IN X JEFFREY COSTELLO 5746473549 615 N MICHIGAN STREET SOUTH BEND IN 46601 X JOHN HILER 2.0 X X 3482 0 0 RICHARD WARNER CSC 2.0 X X 400 0 0 VIVIAN SALLIE 2.0 X X 2562 0 0 RAFAT ANSARI MD 4.0 X 0 460 0 LARRY HARDING 2.0 X X 2562 0 0 VINCENT HENDERSON MD 40.0 X 394421 0 40651 TODD SCHURZ 2.0 X 3501 0 0 PHILIP NEWBOLD 40.0 X X 1001875 0 229464 BIPIN DOSHI 2.0 X 0 0 0 JAMES KEENAN 2.0 X 0 2073 0 WES WILLIAMS 2.0 X 3051 0 0 RICHARD RICE 2.0 X 3051 0 0 TRACY D GRAHAM 2.0 X 0 0 0 JEFFREY COSTELLO 40.0 X 469348 0 99022 MICHAEL O'NEIL 40.0 X 347315 0 34407 GREG CONRAD 8.0 X 39145 156581 25999 MICHAEL GORDON 40.0 X 254903 0 38808 BRYAN BOYER MD 40.0 X 597326 0 35207 OMAR A ALI 40.0 X 503386 0 0 RAMANAK MITRA MD 40.0 X 898591 0 23797 DAVID HORNBACK MD 40.0 X 953709 0 35235 DANIEL MENG MD 40.0 X 507095 0 26780 THEODORE FOTI 18.0 X 119914 0 16094 6105637 159114 605464 109 true true false CERNER CORPORATION 2800 ROCKCREEK PKWY KANSAS CITY MO 46117 IS SFTWR MAINTENANCE 1601286 WOODCOX BLDG CONTRACTORS 51175 PRESCOTT AVE SOUTH BEND IN 46637 CONSTRUCTION MANAGER 1509014 MCKESSON INFORMATION SOLUTIONS LLC PO BOX 98347 CHICAGO IL 60693 IS SFTWR MAINTENANCE 1444864 BVK 250 W COVENTRY COURT MILWAUKEE WI 53217 ADVERTISING 949258 SOFTWARE INFORMATION SYSTEMS LLC 455 PARK PLACE SUITE 301 LEXINGTON KY 40511 IS SFTWR MAINTENANCE 939357 34 629455 1336969 1966424 NET PATIENT REV 621110 44126035 44043591 82444 CLINICAL TRIAL REV 621500 278051 278051 MGT ADMIN SVCS 561499 22399661 20211851 2187810 JOINT VENTURES 621110 250905 219737 31168 AFFILIATE RENT 531120 739155 739155 67793807 168507 168507 0 273 273 4060167 2182416 1877751 1877751 4770 1872981 2997766 1206812 2946381 822589 51385 384223 435608 435608 0 0 0 PROFESSIONAL CALL VOLUME - ASK A NURSE HOTLINE 621300 130570 130570 MEDICAL DIRECTORSHIP 561499 166166 166166 REAL PROPERTY TAX REFUND FROM ST JOSEPH COUNTY 531120 183478 183478 45055 11562 4963 28530 525269 72767639 64764792 2311155 3725268 86482 86482 243263 243263 0 0 2972768 646562 2326206 0 0 46154601 40239063 5915538 0 2369636 1053906 1315730 0 5907557 5692069 215488 0 2854002 2206556 647446 0 0 0 0 0 102163 2561 99602 0 150013 14308 135705 0 7072 3145 3927 0 0 0 0 0 0 0 4002691 2802439 1200252 0 1978829 891301 1087528 0 11733145 8331732 3401413 0 22663 12777 9886 0 0 0 0 0 2630549 1984500 646049 0 277253 148240 129013 0 0 0 0 0 252564 209829 42735 0 0 0 0 0 0 0 0 0 5472711 3229068 2243643 0 1001406 873634 127772 0 BAD DEBT EXPENSE 1896288 1896288 0 0 LICENSES & TAXES 771515 505467 266048 0 GENERAL DUES & SUBSCRIPTIONS 317903 200973 116930 0 OTHER EXPENSE 890859 528057 362802 0 92095933 71802220 20293713 0 5631 5781 3603302 2879783 387424 304670 5304563 5963233 197 106522 5583920 5304783 108924189 46975598 62915962 61948591 3521702 3850908 15263365 15623397 3493104 4006648 100079170 99994316 14583684 11775949 26743 26636 34439046 34845691 49049473 46648276 X 51029697 53346040 51029697 53346040 100079170 99994316 X -19328294 21644637 X false true true X true true X 1287379 831024 1265409 1791723 1966424 7141959 60054785 63654671 62463577 66413343 67810140 320396516 61342164 64485695 63728986 68205066 69776564 327538475 0 0 0 0 0 27869255 29878877 22391069 20657376 19468541 120265118 27869255 29878877 22391069 20657376 19468541 120265118 207273357 2536939 2904040 3258293 2405482 4224177 15328931 4206 4830 4867 4893 4963 23759 2541145 2908870 3263160 2410375 4229140 15352690 316246 583054 388924 395391 325266 2008881 64199555 67977619 67381070 71010832 74330970 344900046 0.60097 0.57336 0.04451 0.04279 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 7071 7071 false OTHER ACTIVITIES PART II-B MEMORIAL HEALTH SYSTEM, INC PAYS FOR THE MEMBERSHIP FEES TO SEVERAL NATIONAL ORGANIZATIONS FOR ITS EMPLOYEES. THESE NATIONAL ORGANIZATIONS INDICATE A PORTION OF THE MEMBERSHIP FEES ARE USED FOR LOBBYING PURPOSES. THE MEMBERSHIP FEES PAID WERE FOR THE FOLLOWING ORGANIZATIONS: -AMERICAN INSTITUTE OF CERTIFIED PUBLIC ACCOUNTANTS -AMERICA COLLEGE OF HEALTH CARE EXECUTIVES -AMERICAN DIETETIC ASSOCIATION -FINANCIAL EXECUTIVE INSTITUTE -MEDICAL GROUP MANAGEMENT ASSOCIATION -AMERICAN ACADEMY OF FAMILY PHYSICIANS -AMERICAN COLLEGE OF PHYSICIANS -AMERICAN COLLEGE OF CARDIOLOGY 16819050 16819050 49446631 15114614 34332017 1950533 1386839 563694 40707975 30474145 10233830 61948591 0 0 ACCRUED SUPPLEMENTAL BENEFITS 4577180 ACCRUED PENSION 29809442 CEO DEFERRED INCENTIVE 447831 NOTE PAYABLE - MADISON CENTER 11238 34845691 true true true X true X true false false 518730 518730 0.00770 8481419 8723816 0.12630 9000149 9242546 0.13400 86482 86482 0.00130 86482 86482 0.00130 9086631 9329028 0.13530 false 1723395 172340 15904181 22438915 -6534734 X true true MEMORIAL SPINE & NEU SPINAL INJECTIONS & OTHER MIN 0.50000 0.50000 LAPORTE MEDICAL GROU OUTPATIENT SURGERY CENTER 0.46670 0.20000 PHYSICIAN'S HOSPITAL LONGTERM ACUTE CARE FACILITY 0.33981 0.25243 0.04369 1 1 RIVERCREST SPECIALTY HOSPITAL

1625 EAST JEFFERSON BLVD MISHAWAKA IN 46545

X LONG TERM ACUTE CARE RIVERCREST SPECIALTY HOSPITAL 1 31 MEMORIAL ADVANCED CARDIOVASCULAR INSTITU

610 N MICHIGAN SUITE 400 SOUTH BEND IN 46601

PHYSICIAN PRACTICE OUTPATIENT SERVICES LAPORTE MEDICAL GROUP

900 I STREET LAPORTE IN 46350

PHYSICIAN PRACTICE OUTPATIENT SERVICES MAIN STREET MEDICAL GROUP

6913 N MAIN STREET SUITE 300 GRANGER IN 46530

PHYSICIAN PRACTICE OUTPATIENT SERVICES LAPORTE LAB

900 I STREET LAPORTE IN 46350

LAB SERVICES IRELAND ROAD MEDICAL GROUP

1815 E IRELAND RD SOUTH BEND IN 46614

PHYSICIAN PRACTICE OUTPATIENT SERVICES LAPORTE SURGERY CENTER

900 I STREET LAPORTE IN 46350

OUTPATIENT SURGERY MICHIANA ARTHRITIS AND OSTEOARTHRITIS CE

707 N MICHIGAN SUITE 102 SOUTH BEND IN 46601

PHYSICIAN PRACTICE OUTPATIENT SERVICES FAMILY PRACTICE CENTER

714 SOUTH MICHIGAN STREET SOUTH BEND IN 46601

PHYSICIAN PRACTICE OUTPATIENT SERVICES NAVARRE PEDIATRIC SATELLITE

6913 N MAIN STREET SUITE 200 GRANGER IN 46530

PHYSICIAN PRACTICE OUTEPATIENT SERVICES RADIATION ONCOLOGY

615 N MICHIGAN STREET SOUTH BEND IN 46601

PHYSICIAN PRACTICE OUTPATIENT SERVICES MEMORIAL SPINE & NEUROSCIENCE CENTER

100 NAVARRE SUITE 4405 SOUTH BEND IN 46601

SPINE & OUTPATIENT SURGERY PROCEDURES WOMEN'S REPRODUCTIVE MEDICINE

100 NAVARRE SUITE 4470 SOUTH BEND IN 46601

PHYSICIAN PRACTICE OUTPATIENT SERVICES MEMORIAL HOSPITALISTS

100 NAVARRE SUITE 5500 SOUTH BEND IN 46601

PHYSICIAN PRACTICE OUTPATIENT SERVICES NAVARRE PEDIATRIC GROUP

100 NAVARRE SUITE 4400 SOUTH BEND IN 46601

PHYSICIAN PRACTICE OUTPATIENT SERVICES SCHWARTZ-WEIKAMP MEDICAL GROUP

4630 VISTULA ROAD MISHAWAKA IN 46544

PHYSICIAN PRACTICE OUTPATIENT SERVICES PORTAGE MEDICAL GROUP

3575 PORTAGE ROAD SOUTH BEND IN 46628

PHYSICIAN PRACTICE OUTPATIENT SERVICES DR BRYAN BOYER

100 NAVARRE SUITE 5500 SOUTH BEND IN 46601

PHYSICIAN PRACTICE OUTPATIENT SERVICES MATERNALFETAL MEDICINE

100 NAVARRE SUITE 4400 SOUTH BEND IN 46601

PHYSICIAN PRACTICE OUTPATIENT SERVICES SOUTHEAST CLINIC

1708 S HIGH STREET SOUTH BEND IN 46613

PHYSICIAN PRACTICE OUTPATIENT SERVICES MEMORIAL CRITICAL KIDS

615 N MICHIGAN SOUTH BEND IN 46601

PHYSICIAN PRACTICE OUTPATIENT SERVICES CENTRAL CLINIC

813 S MICHIGAN STREET SOUTH BEND IN 46601

PHYSICIAN PRACTICE OUTPATIENT SERVICES CENTER FOR OCCUPATIONAL HEALTH

2301 N BENDIX DRIVE SOUTH BEND IN 46628

PHYSICIAN PRACTIVE OUTPATIENT SERVICES SPORTS MEDICINE INSTITUTE

111 W JEFFERSON BLVD SUITE 100 SOUTH BEND IN 46601

PHYSICIAN PRACTICE OUTPATIENT SERVICES PEDIATRIC HEMATOLOGY AND ONCOLOGY

615 N MICHIGAN SOUTH BEND IN 46601

PHYSICIAN PRACTICE OUTPATIENT SERVICES MEDPOINT EXPRESS - VALPARAISO

2400 NORTHLAND DRIVE VALPARAISO IN 46383

PHYSICIAN PRACTICE OUTPATIENT SERVICES DEVELOPMENTAL PEDIATRICS

615 N MICHIGAN SOUTH BEND IN 46601

PHYSICIAN PRACTICE OUTPATIENT SERVICES MEDPOINT EXPRESS - ERSKINE

926 ERSKINE PLAZA SOUTH BEND IN 46614

PHYSICIAN PRACTICE OUTPATIENT SERVICES MEDPOINT EXPRESS - ELKHART

3900 E BRISTOL STREET ELKHART IN 46514

PHYSICIAN PRACTICE OUTPATIENT SERVICES PEDIATRIC SURGERY

615 N MICHIGAN SOUTH BEND IN 46601

PHYSICIAN PRACTICE OUTPATIENT SERVICES LAKEVILLE FAMILY PRACTICE

601 N MICHIGAN LAKEVILLE IN 46536

PHYSICIAN PRACTICE OUTPATIENT SERVICES BARIATRIC SERVICES

6913 N MAIN STREET GRANGER IN 46530

PHYSICIAN PRACTICE OUTPATIENT SERVICES SCHEDULE H, PART I, LINE 3c NOT APPLICABLE SCHEDULE H, PART I, LINE 6a MEMORIAL HEALTH SYSTEM, INC. IS A 33.98% OWNER IN PHYSICIAN'S HOSPITAL, LLC, WHICH IS A TAXABLE ENTITY AND DOES NOT FILE A COMMUNITY BENEFIT REPORT. MEMORIAL HEALTH SYSTEM, INC., OPERATES SEVERAL PHYSICIAN CLINICS THAT PROVIDE SERVICES TO INDIVIDUALS, REGARDLESS OF THEIR ABILITY TO PAY. MEMORIAL'S CENTRAL CLINIC IS LOCATED AT THE SOUTH BEND HOMELESS SHELTER, WHILE THE SOUTHEAST CLINIC IS LOCATED IN A NEIGHBORHOOD WITH HISTORLICLY LOW INCOME LEVELS. SCHEDULE H, PART I, LINE 7, COLUMN F BAD DEBT EXPENSE REMOVED FROM TOTAL EXPENSES OF $1,928,598 SCHEDULE H, PART I, LINE 7 DONATIONS - THE ACTUAL COST OF THE DONATION OR DEPARTMENTAL NET CONTRIBUTION, WHICHEVER IS APPROPRIATE, FROM THE GENERAL LEDGER RECORDS AND REPORTS ARE INCLUDED. SCHEDULE H, PART III, LINE 4 THE CORPORATION EVALUATES THE COLLECTABILITY OF ITS ACCOUNTS RECEIVABLE BASED ON THE LENGTH OF TIME THE RECEIVABLE IS OUTSTANDING, PAYOR CLASS, AND THE ANTICIPATED FUTURE UNCOLLECTIBLE AMOUNTS BASED ON HISTORICAL EXPERIENCE. ACCOUNTS RECEIVABLES ARE CHARGED TO THE ALLOWANCE FOR DOUBTFUL ACCOUNTS WHEN THEY ARE DEEMED UNCOLLECTIBLE. COSTING METHODOLOGY IS THE SAME AS TAX FORM 990, SCHEDULE H, WORKSHEET 2 METHODOLOGY. PATIENT CARE COST ADJUSTED BY NON-PATIENT ACTIVITY, EXPENSES, AND PATIENT CARE CHARGES. SCHEDULE H, PART III, LINE 8 PARTICIPATION IN THE GOVERNMENTAL MEDICARE PROGRAM DOES NOT PROVIDE THE OPPORTUNITY FOR A HEALTH PROVIDER TO NEGOTIATE A REIMBURSMENT RATE OR STRUCTURE THAT WOULD ALLOW THE PROVIDER TO COVER THE COST OF THE MEDICAL SERVICE RENDERED TO THE PROGRAM PARTICIPTANT, AS WOULD BE THE CASE IN CONTRACTUAL NEGOTIATIONS WITH COMMERCIAL INSURANCE COMPANIES. NOR IS THE PROVIDER ALLOWED TO PROVIDE ONLY THE SERVICES FOR WHICH REIMBURSMENT COVERS THE DIRECT COST OF CARE. THIS PRODUCES THE SAME SHORTFALL OUTCOME AS DOES THE PARTICIPATION IN THE MEDICAID PROGRAM. THE MEDICAID PROGRAM IS RECOGNIZED AS A COMMUNITY BENEFIT ON SCHEDULE H AND ON COMMUNITY BENEFIT REPORTS FOR MOST STATES. THE QUALITY AND COST OF THE PATIENT CARE IS THE SAME REGARDLESS OF PAYOR SOURCE. HENCE THE ACCEPTANCE OF MEDICARE REIMBURSMENT REPRESENTS A REDUCTION OR RELIEF OF THE GOVERNMENT BURDEN TO PAY THE FULL COST OF CARE PROVIDED. SCHEDULE H, PART III, LINE 9b The collection policy and procedures are as follows related to patients who are known to qualify for charity care or financial assistance: To ensure that Memorial fulfills its mission and commitment to the poor, Memorial shall annually plan for and provide free health care and health-related services to the poor and qualified uninsured/underinsured. A patient is considered for Financial Assistance if all other State and Federal assistance opportunities have been exhausted. The Federal Income and Poverty Guidelines will serve as a guide in determining those patients that may qualify for Financial Assistance. All patients shall be treated consistently in the approval process including Medicare and non Medicare patients. PURPOSE: To provide financial assistance to those patients who cannot afford to pay and to provide discounted care to uninsured patients receiving healthcare services from Memorial Health System. PROCEDURE: 1.Memorial Health System will assist patients in making a determination regarding whether or not the patient may be able to qualify for some form of entitlement through a Federal or State Government program and complete the appropriate applications for assistance. It is required that the patient will assist in the determination and application process. If the patient does not qualify for any Federal or State Assistance, we will start the Financial Assistance Approval process. 2.Identify patients potentially eligible for Financial Assistance through the pre-registration, admission, eligibility process, or through self pay account review and collection activities. 3.Provide to the patient a Financial Evaluation form. 4.Obtain or receive a signed, completed Financial Evaluation Form from the patient. 5.Determine eligibility by obtaining the following information from the patient: a)Gross income and most recent W-2 b)Prior years tax return (including all schedules) c)Last 3 pay stubs (if unemployed, Work One statement of earnings) d)Employment status and future earnings capacity e)Family size f)Medical expenses including drugs and medical supplies g)Last three bank statements If the patient does not have a prior year tax return, we will make our determination based on current income. A credit report may be run to substantiate documentation. There may be circumstances where a patient may not be able to provide all the above documentation needed to approve financial assistance. It will be up to the discretion of the Department Director and/or the CFO to grant approval in this circumstance. 6.Determine the amount of Financial Assistance by utilizing the Federal Poverty guidelines as a basis for qualification levels. Gross Annual income plus cash assets are used as the basis for income calculations. Financial Assistance will be granted for those patients who are homeless. If a patient is deceased and has no estate, we will grant charity on any outstanding self pay account balances. Documentation that an estate has not been filed will be attached to the Financial Assistance approval form. Note: Approval may be made based on Medical indigence. ie: Patients who have excessive pharmacy, oxygen, or ongoing medical expense. This amount would be deducted from their gross income. Financial Assistance will not be granted for non-medically necessary services. 7.Complete the Financial Assistance Approval form and forward to the Collection Coordinator. 8.The Collection Coordinator will review the Financial Assistance application to ensure that it is complete. The Coordinator will approve or deny the application before sending it to the Patient Account Manager for approval. Depending on the dollar amount of the financial assistance write off, approval signatures are required. The approval guidelines are as follows: $1.00 to $2,500.00 Collection Coordinator $2,501.00 to $10,000.00 Patient Account Service Manager $10,001.00 to $25,000.00 Director, Patient Account Services $25,001.00 and above Vice President, CFO 9. After all the appropriate signatures have been obtained, the Financial Assistance write off along with the corresponding documentation will be forwarded to Cash Application for write off. 10.Send determination letter to notify patient of the approval for Financial Assistance. 11.Financial Assistance approvals will apply retroactively to all open accounts with existing balances (including accounts in collections) and will be active for 6 months following the date of approval. 12.The document will be placed in the Financial Assistance file drawer under the date the write off was posted. UNINSURED SELF PAY DISCOUNTS For those patients who have no insurance and do not meet the above financial assistance guidelines, Memorial Health System will provide an uninsured discount based on the following tiered structure: 30% discount if account is paid within 30 days from date of service 20% discount if account is paid within 90 days from date of service 10% discount if patient chooses to participate in the CarePayment financing Any exceptions must be approved by the Department Manager or Director. SCHEDULE H, PART VI, LINE 3 PHYSICIAN'S HOSPITAL, LLC IS DEDICATED TO SERVICING THE HEALTH CARE NEEDS OF ITS PATIENTS NEEDING FINANCIAL ASSISTANCE. PATIENTS NEED ONLY REQUEST FINANCIAL ASSISTANCE, AND COMPLETE AND SIGN A FINANCIAL ASSISTANCE APPLICATION TO BE CONSIDERED. SCHDULE H, PART VI, LINE 4 ESTABLISHED IN 1830, ST JOSEPH COUNTY INDIANA HAS BECOME THE FOURTH LARGEST COUNTY IN INDIANA. THE COUNTY SPANS 467 SQUARE MILES, WHICH INCLUDES A COMFORTABLE MIX OF RUAL CULTRUAL HERITAGE AND URBAN AMENITIES. THE POPULATION FOR ST. JOSEPH COUNTY IN 2010 WAS 268,299 INDIVIDUALS. THE RACE IN THE COUNTY IS 80% CAUCASIANS, 11.8% AFRICAN AMERICAN, AND HISPANICS REPRESENT 6.6%, WITH 1.6% LISTED AS OTHER. OUR SERVICE AREA INCLUDES PATIENTS FROM ST. JOSEPH COUNTY AND SURROUNDING COUNTIES IN INDIANA AND MICHIGAN. SCHEDULE H, PART VI, LINE 6 MEMORIAL HEALTH SYSTEM, INC. IS A 33.98% OWNER IN PHYSICIAN'S HOSPITAL, LLC. PHYSICIAN'S HOSPITAL, LLC, DOING BUISNESS AS RIVERCREST SPECIALTY HOSPITAL (THE "HOSPITAL") PROVIDES INPATIENT LONG-TERM ACUTE CARE SERVICES. THE HOSPITAL OPERATES A 30 BED, FREESTANDING SPECIALTY ACUTE CARE HOSPITAL LOCATED IN MISHAWAKA, INDIANA. THE HOSPITAL PROVIDES SHORT-TERM, COMPREHENSIVE REHABILITATION SERVICES TO PATIENTS, AND ITS PROGRAMS ARE DESIGNED TO RESTORE PHYSICAL FUNCTIONS FOLLOWING AN ACUTE ILLNESS OR TRAUMA. INPATIENT THERAPY AND SUPPORT SERVICES PROVIDED BY THE HOSPITAL INCLUDE PHYSICAL, OCCUPATIONAL, SPEECH AND RECREATION THERAPY, RADIOLOGY, VENTILATORS, LABORATORY AND DIETARY SERVICES. SCHEDULE H, PART VI, LINE 7 MEMORIAL HEALTH SYSTEM, INC. IS A 33.98% OWNER IN PHYSICIAN'S HOSPITAL, LLC. PHYSICIAN'S HOSPITAL LLC, DOES NOT CURRENTLY FILE A COMMUNITY BENEFIT REPORT. true ALS THERAPY DEVELOPMENT FOUNDATION 215 FIRST STREET CAMBRIDGE MA 02142 043462719 501(c)(3) 5144 SPONSORSHIP:FRIENDS FOR FAY EVENT DOWNTOWN SOUTH BEND INC 217 S MICHIGAN ST SOUTH BEND IN 46601 351546291 501(c)(6) 50000 2010 PLEDGE 1 1 SCHOLARSHIPS/TUITION REIMBURSMENT 136 329745 SCHEDULE I, PART II CHARITABLE DONNATIONS PART OF THE ORGANIZATION'S MISSION IS TO IMPROVE THE HEALTH OF OUR COMMUNITY. IN ORDER TO FULFUILL THIS GOAL, OUR ADMINISTRATORS HAVE THE ABILITY TO MAKE DONATIONS TO ORGANIZATIONS THAT IMPROVE THE HEALTH AND WELL BEING OF OUR COMMUNITY. SCHEDULE I, PART III SCHOLARSHIPS / TUITION REIMBURSMENT FOR SCHOLARSHIPS THE INDIVIDUAL MUST MEET SEVERAL REQUIREMENTS TO QUALIFY. IN ORDER TO QUALIFY FOR A SCHOLARSHIP THE INDIVIDUAL MUST (1) APPLY ON-LINE (INTRANET) AND WITHIN THE ACCEPTABLE TIME PARAMETERS FOR THE SEMESTER OF FUNDS BEING REQUESTED, (2) MAINTAIN A GRADE OF C OR BETTER, (3) PAY FOR TUITION/BOOKS AND SUBMIT CORRESPONDING ORIGINAL RECEIPTS FOR REIMBURSEMENT. REIMBURSED UP TO THE AMOUNT AWARDED BY THE SCHOLARSHIP COMMITTEE. (4) MEET ANY ADDITIONAL REQUIREMENTS OF THE SPECIFIC SCHOLARSHIP FUND, AND (5) MEET ELIGIBILITY REQUIREMENTS WHICH INCLUDE: (A) EMPLOYED BY MEMORIAL HEALTH SYSTEM, INC. (B) ENROLLED IN A QUALIFIED PROGRAM; (C) SUBMITTED A POSITIVE RECOMMENDATION EACH SEMESTER FROM THE IMMEDIATE SUPERVISOR; AND (D) SUBMITTED A POSITIVE RECOMMENDATION EACH SEMESTER FROM THE SCHOOL. X X X X true true X X X X X false true false false false true true true false VINCENT HENDERSON MD 359086 0 30625 0 4710 0 27431 0 13220 0 435072 0 0 0 THEODORE FOTI 115754 0 0 0 4160 0 0 0 16094 0 136008 0 0 0 JEFFREY COSTELLO 273186 0 106000 0 90162 0 84363 0 14659 0 568370 0 0 0 MICHAEL O'NEIL 213113 0 80860 0 53342 0 24147 0 10260 0 381722 0 0 0 PHILIP NEWBOLD 556903 0 304355 0 140617 0 210175 0 19289 0 1231339 0 140555 0 MICHAEL GORDON 208224 0 41547 0 5132 0 20270 0 18538 0 293711 0 0 0 BRYAN BOYER MD 596352 0 0 0 974 0 13402 0 21805 0 632533 0 0 0 OMAR A ALI 499990 0 2916 0 480 0 0 0 0 0 503386 0 0 0 RAMANAK MITRA MD 871816 0 25725 0 1050 0 12250 0 11547 0 922388 0 0 0 GREG CONRAD 31687 126748 6514 26057 944 3776 3155 12620 2045 8179 44345 177380 0 0 DAVID HORNBACK MD 596051 0 356278 0 1380 0 12250 0 22985 0 988944 0 0 0 DANIEL MENG MD 499378 0 4657 0 3060 0 7502 0 19278 0 533875 0 0 0 PART I, LINE 1A MEMORIAL HEALTH SYSTEM, INC. REIMBURSES DIRECTORS FOR THE TAX EFFECT OF THE 1099 REPORTABLE BENEFITS FOR HEALTH CLUB MEMBERSHIP, WITH MEMORIAL HEALTH SYSTEM'S HEALTH AND LIFESTYLE CENTER AND SPOUSAL TRAVEL. THIS REPORTING IMPACTS 7 CURRENT BOARD MEMBERS. MEMORIAL HEALTH SYSTEM ALSO REIMBURSES FOR DIRECT EXPENSES RELATED TO ANY TRAVEL ON MEMORIAL HEALTH SYSTEM'S BEHALF. SOCIAL CLUB MEMBERSHIPS INCLUDED IN TAXABLE COMPENSATION - 2 EMPLOYEES (JEFFERY COSTELLO, AND MICHAEL O'NEIL) SPOUSAL TRAVEL INCLUDED IN TAXABLE COMPENSATION -1 EMPLOYEE (PHILIP NEWBOLD) CHARTER TRAVEL FOR INVESTMENT COMMITTEE MEMBERS TO TRAVEL TO INVESTMENT ADVISOR, LOCATED IN MINNEAPOLIS. CHARTER TRAVEL ALLOWED THE ORGANIZATION TO REDUCE THE OVERALL COST OF TRAVEL, BY ELIMINATING THE NEED FOR OVER NIGHT ACCOMMODATIONS. THE CHARTER TRAVEL ALSO REDUCED THE TIME UNPAID BOARD MEMBERS HAD TO COMMIT. (2 INDIVIDUALS LISTED ON PART VII, SECTION LINE 1A - JEFFREY COSTELLO, AND JAMES KEENAN) PART I, LINE 4B SUPPLEMENTAL EXECUTIVE RETIREMENT PROGRAM (457(F)) EMPLOYEE 2010 EARNED 457(f) PHILIP NEWBOLD $108,930 MICHAEL O'NEIL $32,493 JEFFERY COSTELLO $66,001 MEMORIAL HEALTH SYSTEM PROVIDES A NON-QUALIFIED SUPPLEMENTAL EXECUTIVE RETIREMENT PROGRAM (SERP) TO CERTAIN EXECUTIVES. THE PLAN PROVIDES FOR AN ADDED RETIREMENT BENEFIT OVER THE QUALIFIED RETIREMENT PROGRAM. QUALIFIED INDIVIDUALS ARE ELIGIBLE TO RECEIVE A BENEFIT, IN THE FORM OF AN AFTER TAX LUMP SUM, WHICH IS THE ACTUARIAL EQUIVALENT OF AN ANNUITY, EQUAL TO 65% OF THE AVERAGE OF THEIR LAST FIVE YEARS OF PRERETIREMENT EARNINGS, OR 70% WITH MORE THAN 25 YEARS OF SERVICE, WITH OFFSETS FOR THE VALUE OF SOCIAL SECURITY AND QUALIFIED RETIREMENT PLAN BENEFITS. PARTICIPANTS VEST INTO THE SERP AFTER FIVE YEARS OF SERVICE. THE INCREASE IN VALUE OF THE BENEFIT EACH YEAR IS INCLUDED IN THE TAXABLE COMPENSATION OF VESTED SERP PARTICIPANTS. SUCH AMOUNTS ARE INCLUDED IN PART II COLUMN (B)(iii). THE ANNUAL VALUE OF THE BENEFIT IS CONVERTED TO A LUMP SUM AND PAID TO THE PARTICIPANT AFTER FULFILLING THE TERMS OF THEIR NON-COMPETE AGREEMENT. PART I, LINE 6A & 6B THE ORGANIZATION HAS TWO INCENTIVE PLANS (EMPLOYEE AND MANAGEMENT) WHICH HAVE A NET OPERATING INCOME TO BUDGET MEASUREMENT FOR THE PAYOUT THRESHOLD. THE EMPLOYEE PLAN SHARES THE EXCESS OVER BUDGET NET OPERATING INCOME WITH THE NON-MANAGMENT EMPLOYEES FOR MEMORIAL HEALTH SYSTEM, INC AND THE AFFILIATED ENTITIES, WHICH INCLUDES MEMORIAL HOSPITAL OF SOUTH BEND, INC. THE EMPLOYEE INCENTIVE HAS A MAXIMUM CAP OF $2,500,00. THE MANAGEMENT INCENTIVE PLAN PAYS A SLIDING PERCENTAGE OF BASE COMPENSATION IF THE NET OPERATING INCOME IS EQUAL TO OR GREATER THAN 80% OF THE BUDGETED NET OPERATING INCOME. THE SLIDING SCALE CAPS WHEN OPERATING INCOME REACHES 120% OF THE BUDGETED OPERATING INCOME. PART I, LINE 7 BRYAN BOYER, MD IS ELIGIBLE FOR AN INCENTIVE BASED UPON EXCEEDING GROSS PROFESSIONAL BILLINGS. THE INCENTIVE IS A COMPONENT OF THE EMPLOYMENT CONTRACT WITH DR. BOYER. DR. BOYER DID NOT QUALIFY FOR AN INCENTIVE PAYMENT IN 2010. DAVID HORNBACK, MD RECEIVED AN INCENTIVE BASED UPON NET PREOFESSIONAL BILLINGS. THE INCENTIVE IS A COMPONENT OF THE EMPLOYMENT CONTRACT. FACULTY INCENTIVE FOR FAMILY PRACTICE RESIDENCY CLINICS PROVIDES FOR AN INCENTIVE PAYMENT WHEN COLLECTIONS FOR PERSONALLY RENDERED SERVICES EXCEED A THRESHOLD. THESE INCENTIVE ARE CAPPED. PHYSICIAN RELATIONS INCENTIVE PLAN PROVIDES FOR AN INCENTIVE PAYMENT TO EMPLOYEES IN A PHYSICIANS RELATIONS POSITION BASED UPON ATTAINMENT OF SATISFACTION SCORES. PAID AS A PERCENTAGE OF BASE PAY UP TO 5%. RAFAT ANSARI MD DIRECTOR 525037 LEASES OFFICE SPACE false FORM 990, PART VI, SECTION A, LINE 2 BUSINESS RELATIONSHIPS - TERRY GERBER & JOHN HILER BUSINESS RELATIONSHIPS - VINCENT HENDERSON & RICK RICE FORM 990, PART VI, SECTION B THE ORGANIZATION HAS WRITTEN POLICIES AND PROCEDURES THAT COVER NUMEROUS TOPICS. THESE POLICIES AND PROCEDURES WERE NOT APPROVED BY THE GOVERNING BOARD IN THE CURRENT TAX YEAR, BUT WILL BE REVIEWED AND APPROVED BY THE GOVERNING BOARD IN FUTURE YEARS. A FEW OF THE TOPICS COVERED BY THE CURRENT POLICIES AND PROCEDURES OF THE ORGANIZATION ARE: - LOCAL CHAPTERS, BRANCHES AND AFFILIATES - CONFLICT OF INTEREST - WHISTLEBLOWER - DOCUMENT RETENTION AND DESTRUCTION - JOINT VENTURES FORM 990, PART VI, SECTION B, LINE 11b THE ORGANIZATION INCORPORATES NUMEROUS PARTIES IN THE PRODUCTION AND REVIEW OF THE FORM 990 AND ASSOCIATED SCHEDULES. SENIOR ACCOUNTING STAFF AND MANAGEMENT COMPLETE THE FORM 990 AND SCHEDULES. THE FORMS AND SCHEDULES ARE REVIEWED BY THE ACCOUNTING MANAGER, CONTROLLER, AND CFO. SUBSEQUENT TO THOSE STEPS, THE ORGANIZATION ENGAGED ERNST & YOUNG US, LLP TO REVIEW THE COMPLETED FORM 990 AND APPROPRIATE SCHEDULES. PRIOR TO FILING THE RETURN, THE COMPENSATION COMMITTEE OF THE ORGANIZATION AND CEO CONDUCT A GENERAL OVERVIEW OF THE FORM 990, INCLUDING APPLICABLE COMPENSATION SCHEDULES. IN ADDITION, THE BOARD OF DIRECTORS AND THE AUDIT COMMITTEE WILL RECEIVE A COPY OF THE 990 PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12c THERE ARE THREE SEPARATE FORMS THAT ARE SENT OUT THROUGH THE INTERNAL AUDIT DEPARTMENT TO KEY EMPLOYEES OR BOARD MEMBERS REGARDING CONFLICT OF INTEREST. THEY ARE AS FOLLOWS: 1. THE FIRST IS A CONFLICT OF INTEREST STATEMENT THAT IS SENT TO SENIOR LEVEL ADMINISTRATION, MANAGEMENT, AND SELECT STAFF SUCH AS PURCHASING DEPARTMENT EMPLOYEES. THE PURPOSE OF THE STATEMENT IS TO REQUIRE EMPLOYEES TO DISCLOSE ANY POTENTIAL CONFLICT OF INTERESTS THEY MAY HAVE. THE STATEMENTS ARE SENT IN JANUARY OF EACH YEAR AND WE PURSUE THE REPLIES TO GET A 100% RESPONSE RATE. IN THE CURRENT YEAR WE SENT OUT OVER 250 STATEMENTS AND ACHIEVED A 100% RESPONSE RATE. EACH RESPONSE IS REVIEWED BY THE DIRECTOR OF INTERNAL AUDIT AND THE RESULTS ARE REPORTED TO THE CEO OF MEMORIAL HEALTH SYSTEM, INC AS WELL AS THE AUDIT COMMITTEE OF THE BOARD OF DIRECTORS. 2.THE SECOND STATEMENT IS THE BOARD DUALITY OF INTEREST STATEMENT THAT IS SENT TO CURRENT BOARD MEMBERS, FORMER BOARD MEMBERS FROM THE LAST FIVE YEARS, THE FIVE HIGHEST COMPENSATED EMPLOYEES FROM THE PREVIOUS YEAR, EMPLOYEES THAT ARE ON THE GRANT AND SCHOLARSHIP COMMITTEES, AND OTHER KEY EMPLOYEES. THE DUALITY OF INTEREST STATEMENTS WERE SENT OUT IN MAY, 2010. THE REPLIES ARE REVIEWED BY THE DIRECTOR OF INTERNAL AUDIT WHO SUMMARIZES THE RESULTS, WHICH ARE REVIEWED BY AN INDEPENDENT PARTY. THE RESULTS ARE REPORTED TO THE CEO OF MEMORIAL HEALTH SYSTEM, INC AND THE AUDIT COMMITTEE OF THE BOARD OF DIRECTORS. 3. THE THIRD STATEMENT IS ENTITLED "CODE OF ETHICS FOR SENIOR FINANCIAL OFFICERS." THE STATEMENT REQUIRES AN ACKNOWLEDGMENT FORM TO BE SIGNED BY MEMORIAL HEALTH SYSTEM, INC'S KEY FINANCIAL EMPLOYEES THAT MEMORIAL HEALTH SYSTEMS, INC'S FINANCIAL INFORMATION IS TO THE BEST OF THEIR KNOWLEDGE TRUE AND ACCURATE. THIS STATEMENT WAS SENT OUT IN JANUARY, 2010. SIGNED ACKNOWLEDGEMENTS ARE KEPT BY THE DIRECTOR OF INTERNAL AUDIT. IN 2010, FOURTEEN DESIGNATED EMPLOYEES WERE REQUESTED TO SIGN THE FORM AND 100% COMPLIED WITH THIS REQUEST. ANY POTENTIAL CONFLICTS OF INTERESTS ARE REVIEWED BY INDEPENDENT PARTIES BOTH INTERNAL AND EXTERNAL TO THE ORGANIZATION, AND IF NECESSARY, CORRECTIVE ACTION WOULD BE TAKEN TO RESOLVE A TRUE CONFLICT. THE INDIVIDUAL WITH THE POTENTIAL CONFLICT OF INTEREST IS EXCLUDED FROM ALL REVIEW PROCEEDINGS FORM 990, PART VI, SECTION B, LINE 15a & 15b AN EXTENSIVE EXAMINATION IS CONDUCTED USING COMPARABLE MARKET DATA AND IT IS THEN REVIEWED BY AN INDEPENDENT CONSULTANT HIRED BY, AND REPORTING TO, THE BOARD OF DIRECTORS. RECOMMENDATIONS ARE PRESENTED TO THE COMPENSATION COMMITTEE OF THE MEMORIAL HEALTH SYSTEM, INC BOARD FOR DELIBERATION AND FINAL DECISION. DELIBERATION AND FINAL DECISION ARE PERFORMED BY THE INDEPENDENT MEMBERS OF THE BOARD. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE PUBLIC. THE FINANCIAL STATEMENTS ARE DISTRIBUTED QUARTERLY TO THE ELECTRONIC MUNICIPAL MARKET ACCESS (EMMA) WEBSITE AS PART OF THE CONTINUING DISCLOSURES FOR THE MEMORIAL HEALTH SYSTEM, INC. BONDS. FORM 990, PART XI, LINE 5 CASH TRANSFERS FROM MEMORIAL HOSPITAL OF SOUTH BEND: $18,686,057 WRITE OFF INTER COMPANY MEMORIAL HOSPITAL OF SOUTH BEND $ 2,506,736 WRITE OFF INTER COMPANY MEMORIAL HEALTH FOUNDATION $-1,367,336 CHANGE IN PENSION LIABILITY $ 1,498,690 UNREALIZED GAINS/LOSS ON DEFERRED COMPENSATION PLAN $ 137,556 CHANGE IN MARKET VALUE ON LIFE INSURANCE PLANS $ 182,933 TOTAL $21,644,636 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:RAFAT ANSARI, MD TITLE:DIRECTOR - MED DIRECTOR HOURS:40 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:GREG CONRAD TITLE:ASST SECRETARY HOURS:32 MEMORIAL HOSPITAL OF SOUTH BEND INC 615 N MICHIGAN ST SOUTH BEND IN 46601 350868132 HOSPITAL IN 501(c)(3) 3 MHS MEMORIAL HEALTH FOUNDATION INC 615 N MICHIGAN ST SOUTH BEND IN 46601 351536129 FINANCIAL SUP IN 501(c)(3) 9 MHS MEMORIAL HOME CARE INC 615 N MICHIGAN ST SOUTH BEND IN 46601 351901068 HOME MEDICAL IN C 21646538 13609358 1.00000 true true true false false false true true true true true true true true true true true true MEMORIAL HOME CARE INC a iv 77017 MEMORIAL HOSPITAL OF SOUTH BEND INC a iv 743834 MEMORIAL HOME CARE INC j 75254 MEMORIAL HOSPITAL OF SOUTH BEND INC j 204612 MEMORIAL HEALTH FOUNDATION INC b 1367336 MEMORIAL HOSPITAL OF SOUTH BEND INC c 21192793 MEMORIAL HEALTH FOUNDATION INC c 629455 MEMORIAL HOME CARE INC k 4538767 MEMORIAL HOSPITAL OF SOUTH BEND INC k 180192059 MEMORIAL HOSPITAL OF SOUTH BEND INC l 19804289 MEMORIAL HOME CARE INC l 1382156 MEMORIAL HEALTH FOUNDATION INC l 407562 MEMORIAL HEALTH FOUNDATION INC n 583396 MEMORIAL HOME CARE INC p 3760484 MEMORIAL HOSPITAL OF SOUTH BEND INC p 27186057 MEMORIAL HEALTH FOUNDATION INC p 155000 MEMORIAL HEALTH FOUNDATION INC q 678451 MEMORIAL HOME CARE INC q 4740168 MEMORIAL HOSPITAL OF SOUTH BEND INC q 32412014 MEMORIAL HEALTH FOUNDATION INC r 711906 MEMORIAL HOME CARE INC r 4302378 MEMORIAL HOSPITAL OF SOUTH BEND INC r 34918749