2022-01-18T13:06:47-06:00 2020-06-30 420714325 RSM US LLP 30 S Wacker Drive Ste 3300 Chicago IL 60606 990 2019-07-01 300072647 Wisconsin Dialysis Inc WISC 6082705600 3034 Fish Hatchery Road Fitchburg WI 53713 Jodilynn Vitello VP of Finance 6082705600 2022-01-10 1 Rebekuh Eley P01247672 3126343400 2019 2022-09-23 18:48:47Z X Mary Link 3034 Fish Hatchery Road Fitchburg WI 53713 61789372 0 X www.wisconsindialysis.org X 2002 WI To provide outpatient kidney dialysis treatments for patients in a clinic or home based setting according to the regulations established by the Centers for Medicare & Medicaid. X 5 0 0 0 288478 -669818 200 500 17639637 4729802 147336 55720962 33730 0 17820903 60451264 0 0 0 0 6239292 4594836 0 0 0 10068985 1518387 16308277 6113223 1512626 54338041 18230807 35354594 1195829 574312 17034978 34780282 X Through October 7, 2019, Wisconsin Dialysis, Inc. exists to provide In-Center, Home, and Inpatient Dialysis to patients in Central Wisconsin with End State Renal Disease. As a result of the contribution on 10/7/19, Wisconsin Dialysis, Inc. no longer provides services and holds a 30% membership interest in Fresenius Kidney Care of Madison, LLC. 0 1 5308546 4729802 Wisconsin Dialysis, Inc. provides dialysis care to End Stage Renal Disease patients throughout Central Wisconsin, with clinics in Fitchburg and Madison, home services, and inpatient care. From July 1, 2019 through October 7, 2019, Wisconsin Dialysis provided 9,963 treatments. Wisconsin Dialysis also focused on home patient training with an eye to encourage fewer hospitalizations in the future. Wisconsin Dialysis services are governed by CMS (Medicare) and must meet a set of Clinical Standards established through the Quality Improvement Program (QIP). Patient Data is reported on a regular basis to CMS. On 10/7/2019, WDI contributed substantially all of the assets used in its business to Fresenius Kidney Care Madison, LLC. WDI retains a 30% membership interest in Fresenius Kidney of Madison. UWHCA retained a 45% membership interest, Unity Point-Meriter retained a 45% membership interest, and UWMF retained a 10% membership interest in WDI. 5308546 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 1 0 0 0 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 X 5 0 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 1 0 X Aaron Prochaska 6088214272 7974 UW Health Court Middleton WI 53562 Dr Jeff Pothof Director 0.30 39.70 X 0 487671 83283 Mary Link President 0.30 39.70 X X 0 364685 105336 Jodi Vitello Director 0.30 39.70 X 0 384044 80883 Karil Walther VP Primary Care 0.30 39.70 X 0 291921 56305 Ronald Schroeder Treasurer 0.50 39.50 X X 0 225679 29879 Karen Schlageter RN Clinic Manager 32.00 8.00 X 0 180912 37527 Tami Morin Secretary 36.00 4.00 X 0 174604 33542 Kristine Holmes RN Director 1.00 39.00 X 0 174858 22218 Diane Marie Haag Care Team Leader 32.00 8.00 X 0 157026 32592 Sarah Clark In Patient RN 32.00 8.00 X 0 119806 33147 0 2561206 514712 0 0 1 0 Medefis Inc PO Box 5068 New York NY 10087 Agency Staffing 1399253 Foundation Medical Staffing 416 W 15th Street 600 Edmond OK 73013 Agency Staffing 1132935 University of Wisconsin Medical Foundati 7974 UW Health Court Middleton WI 53562 Medical Director Fees 128257 Dialysis Solutions LLC 1961 Hillcrest Drive Delafield WI 53018 Repairs and Maintenance 116834 4 500 500 Outpatient Revenue 621400 4351168 4351168 Inpatient Revenue 621990 223976 223976 Equity Interest in JV 621400 154658 154658 4729802 188771 142924 45847 56870299 10428 1327680 -10428 55542619 55532191 -9104 55541295 60451264 4575144 288478 55587142 3328003 2776477 551526 974526 828863 145663 292307 241038 51269 4443 4443 139976 138027 1949 167436 110828 56608 845 596 249 76772 76772 Pharmaceutical Supplies 602879 602879 Medical Supplies 336206 336206 Cleaning Supplies 24802 24802 165028 248830 -83802 6113223 5308546 804677 0 6686440 6788358 2736772 1208373 48836 2238 0 0 1349130 0 7409629 7766769 19516931 0 71925 18230807 35354594 251127 31803 65226 4680 879476 537829 1195829 574312 X 17034978 34780282 17034978 34780282 18230807 35354594 X 54338041 148359 -36741096 X 0 0 0 X X 3 UnityPoint Health-Meriter 390806367 3 1 0 0 Univ of WI Hospitals and Clinics Authority 391835630 6 1 0 0 Univ of WI Medical Foundation Inc 391824445 10 1 0 0 3 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 X 1 1 Part IV, Section A, Line 2 University of Wisconsin Hospitals and Clinics Authority is one of the supported organizations and does not have an IRS determination of status under Section 509(a)(1) or (2). It is not required to obtain recognition of its public charity status because it is considered a governmental unit (public authority, a public body corporate and politic created by Wisconsin statutes). UnityPoint Health-Meriter is one of the supported organizations and does not have an IRS determination of status under Section 509(a)(1) or (2). It is not required to obtain recognition of its public charity status because it is a hospital under Section 170(b)(1)(A)(iii). Part IV, Section D, Line 3 According to the Bylaws of the Organization, there shall be at least 5 Board Members. Two of the Board Members will be appointed by Meriter Hospital, Inc. (one of the three members of the Organization and is a supported organization), two of the Board Members will be appointed by University of Wisconsin Hospitals and Clinics Authority (one of the three members of the Organization and is a supported organization) and one of the Board Members will be appointed by UW Medical Foundation (one of the three members of the Organization and is a supported organization). Each Board Member has a vote. All Board Members must be from one of the three supported organizations. Based on the composition of the Board, all three supported organizations have a significant voice in directing the use of the Organization's income and assets during the year. Part IV, Section E, Line 2A How these activities directly furthered the supported organizations exempt purposes: The Organization is a collaborative project among the three tax-exempt healthcare providers in Madison, Wisconsin (and are the three supported organizations). The three supported organizations formed the Organization to provide comprehensive dialysis services to their patients. The sole activity of the Organization is providing dialysis services. By doing this, the Organization is directly furthering the exempt purposes of the three supported organizations. How the Organization was responsive to those supported organizations: The Organization's Board of Directors is composed of individuals from the three supported organizations. The Board of Directors meet throughout the year to discuss the activities of the Organization to make sure the activities further the exempt purposes of the three supported organizations. How the Organization determined that these activities constituted substantially all of its activities: The Organization was formed to provide comprehensive dialysis services. This is the sole activity of the Organization. Part IV, Section E, Line 2B The three supported organizations are healthcare providers in Madison, Wisconsin. One of the goals of the Organization was to develop and implement a collaborative model for the provision of dialysis services that enable the three supported organizations to work together to provide patient care at a higher level of quality and satisfaction than is achievable through individual efforts. The three supported organizations as healthcare providers would have engaged in this activity (i.e. providing dialysis services) but for the Organization's involvement. 0 Investment in Fresenius Kidney Care Madison LLC 19516931 C 19516931 Due to UWHCA 537829 537829 0 1 0 0 0 0 0 0 0 Dr Jeff Pothof Director 0 415536 0 72135 0 0 0 83220 0 63 0 570954 0 0 Mary Link President 0 293641 0 61950 0 9094 0 46903 0 58433 0 470021 0 0 Jodi Vitello Director 0 318284 0 63840 0 1920 0 48289 0 32594 0 464927 0 0 Karil Walther VP Primary Care 0 242435 0 45378 0 4108 0 43008 0 13297 0 348226 0 0 Ronald Schroeder Treasurer 0 194584 0 30249 0 846 0 9390 0 20489 0 255558 0 0 Karen Schlageter RN Clinic Manager 0 144318 0 26666 0 9928 0 12587 0 24940 0 218439 0 0 Tami Morin Secretary 0 150349 0 15000 0 9255 0 12869 0 20673 0 208146 0 0 Kristine Holmes RN Director 0 156395 0 15933 0 2530 0 7161 0 15057 0 197076 0 0 Diane Marie Haag Care Team Leader 0 145264 0 300 0 11462 0 12069 0 20523 0 189618 0 0 Sarah Clark In Patient RN 0 109642 0 9000 0 1164 0 9483 0 23664 0 152953 0 0 Part I, Line 3 Wisconsin Dialysis, Inc.'s Board Secretary functions as the Organization's Executive Director and compensation is paid by a related organization, University of Wisconsin Hospitals and Clinics Authority (UWHCA). Every 1-2 years, executive compensation is reviewed by UW Health's HR department as part of a compensation study by an independent contractor. Part I, Line 4b Some members of the Board participate in supplemental, non-qualified retirement plans through their employers, which are related organizations to the filing entity. Those individuals participate in a 457(f) plan. In 2019, the following employer contributions were made: - Dr. Jeff Pothof $41,220 - Mary Link $29,500 - Jodi Vitello $30,400 - Karil Walther $6,624 In 2019, no distributions were made. Property, plant, equipment and other intangible assets 2019-10-07 56655647 Arms length transaction 842525990 Fresenius Kidney Care Madison LLC 920 Winter Street Waltham MA 024511457 N/A 0 0 0 0 Form 990, Explanation of Changes: On 10/7/19, WDI contributed substantially all of the assets used in its business to Fresenius Kidney Care Madison, LLC. WDI retained a 30% membership interest in the joint venture. Due to the contribution of assets, WDI is no longer primarily operated for charitable purposes and ceased to be a tax exempt entity under IRC 501(c)(3) as of 10/7/19. The Form 990 is amended to reflect the income from the joint venture arrangement as unrelated business income. Part VIII reflects the changes to income. Part XI, line 9 reflects the book/tax differences between the Form K-1 revenue from the joint venture and the amounts recorded on the books under the equity method of accounting. The changes to the Form 990 resulting from the unrelated business activities are as follows: i. Page 1, box G ii. Part I, line 9 & 10 iii. Part III, line 3 narrative iv. Part III line, 4a revenue v. Part IV line 32 vi. Part V, lines 3a & 3b vii. Part VIII, lines 2a-c, line 3, and line 7 viii. Part XI, Line 9 ix. addition of Schedule N. All unrelated business income for the year ended June 30, 2020 will be reported on Form 990-T for that year. Beginning with the tax year ending June 30, 2021 and all subsequent tax years, WDI will file Form 1120 in lieu of Form 990. Form 990, Part III, line 3 Due to the contribution of assets and business operations to the joint venture on 10/7/2019, WDI is no longer primarily operated for charitable purposes and ceased to be a tax exempt entity under IRC 501(c)(3). WDI has filed Form 990-T to report income from the joint venture arrangement as unrelated business income, for the tax period October 8, 2019 through June 30, 2020. For the tax year ending June 30, 2021 and for all subsequent tax years, WDI will file Form 1120 in lieu of Form 990. Form 990, Part VI, Section A, line 3 DELEGATION OF CONTROL OVER MANAGEMENT DUTIES Wisconsin Dialysis, Inc.'s Board Secretary functions as the Organization's Executive Director and compensation is paid by a related organization, University of Wisconsin Hospitals and Clinics Authority (UWHCA). All management duties are provided for under a Management Services Agreement between WDI and UWHCA. Form 990, Part VI, Section A, line 6 MEMBERS OF THE ORGANIZATION Members are all of one class with a 45% ownership by UnityPoint Health-Meriter, 45% owned by University of Wisconsin Hospitals and Clinics Authority, and 10% owned by University of Wisconsin Medical Foundation. Form 990, Part VI, Section A, line 7a POWER TO ELECT OR APPOINT GOVERNING BODY The Board of Directors will be appointed solely by the Members of Wisconsin Dialysis, Inc. Form 990, Part VI, Section A, line 7b GOVERNANCE DECISIONS RESERVED TO PERSONS OTHER THAN GOVERNING BODY The Members of Wisconsin Dialysis shall have the rights to approve, - Merger, consolidation or dissolution of the Company; - Amendment or restatement of the Articles of Incorporation or the Bylaws of the Company; and - Amendment of Management Services Agreement between the Company and University of Wisconsin Hospitals and Clinics Authority. Form 990, Part VI, Section B, line 11b REVIEW OF FORM 990 BY THE ORGANZATION'S GOVERNING BODY Form 990 is completed by the organization's external accounting firm. Key finance employees reviewed the Form 990 to determine if complete and accurate. The original and amended return were provided to the members of the board of directors with a memorandum related to the amended Form 990 before filing. The original and amended return was submitted for filing with the Internal Revenue Service. Form 990, Part VI, Section B, line 12c MONITORING AND ENFORCING COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY To ensure that the Organization operates in a manner consistent with charitable purposes and that it does not engage in activities that could jeopardize its status as an organization exempt from federal income tax, periodic reviews shall be conducted. The periodic reviews shall, at a minimum, include the following subjects, to the extent such subjects are applicable: 1) Whether compensation arrangements and benefits are reasonable and are the result of arm's length bargaining; 2) Whether acquisitions of physician practices and other provider services result in inurement or impermissible private benefit; 3) Whether partnership and joint venture arrangements and arrangements with management service organizations and physician hospital organizations conform to written policies, are properly recorded, reflect reason able payments for goods and services, further the Organization's charitable purposes and do not result in inurement or impermissible private benefit; 4) Whether agreements to provide health care and agreements with other health care providers, employees, and third party payers further the Corporation's charitable purposes and do not result in inurement or impermissible private benefit; 5) The policy covers all voting and ex-officer Board Members. Anyone found to be in violation of this policy would be recused from voting on and discussion about the transaction or topic. All review activity of actual or potential conflicts takes place at the full board level. Form 990, Part VI, Section C, line 19 AVAILABILIIY OF ORGANZATION DOCUMENTS All referenced documents are available to the public upon request pursuant to the guidelines of Section 6104(d). Form 990, Part XI, line 9: Capital Transferred Out -37,000,000. Book/Tax Difference for Equity Interest in Joint Venture 258,904. Regional Division Inc 7974 UW Health Court No MC1020 Middleton WI 53562 391446049 Regional Parent Corporation to manage and direct activities of entities WI 501(c)(3) Line 12a University of WI Hospitals and Clinics Authority 1 University Health Care Inc 7974 UW Health Court Middleton WI 53562 472553196 Support Organization WI 501(c)(3) Line 12a University of WI Hospitals and Clinics Authority 1 Generations Fertility Care 2365 Deming Way Middleton WI 53562 273496527 Reproductive Endocrinology and Infertility Services WI 501(c)(3) Line 10 N/A 1 University of Wisconsin Medical Foundation 7974 UW Health Court Middleton WI 53562 391824445 Physician Services WI 501(c)(3) Line 10 University of WI Hospitals and Clinics Authority 0 Madison Surgery Center 7974 UW Health Court Middleton WI 53562 391940656 Health Care Services and Training WI 501(c)(3) Line 10 N/A 1 UnityPoint Health-Meriter 202 S Park Street Madison WI 53715 390806367 Hospital WI 501(c)(3) Line 3 N/A 0 University of Wisconsin Hospitals and Clinics Authority 301 S Westfield Road Suite 320 Madison WI 53717 391835630 Hospital WI 115 N/A 0 Transformations Surgery Center 7974 UW Health Court Middleton WI 53562 391948840 Health Care Services and Training WI 501(c)(3) Line 10 N/A 1 Wisconsin Therapies Inc 7974 UW Health Court Middleton WI 53562 391807425 Infusion Therapy WI 501(c)(3) Line 12a University of WI Hospitals and Clinics Authority 1 Wisconsin Sleep Inc 6001 Research Park Blvd Madison WI 53719 260902344 Health Care Services and Training WI 501(c)(3) Line 10 N/A 1 UW Health ACO Inc 7974 UW Health Court Middleton WI 53562 455490584 Accountable Care Organization WI 501(c)(3) Line 10 University of WI Hospitals and Clinics Authority 1 SwedishAmerican Hospital 1401 E State Street Rockford IL 61104 362222696 Hospital IL 501(c)(3) Line 3 SwedishAmerican Health System Corporation 1 SwedishAmerican Foundation 1415 E State Street Rockford IL 61104 363097493 Supporting Fundraising for SwedishAmerican Hospital IL 501(c)(3) Line 7 SwedishAmerican Hospital 1 SwedishAmerican Realty Corporation 1313 E State Street Rockford IL 61104 363248013 Title Holding Company IL 501(c)(2) SwedishAmerican Health System Corporation 1 SwedishAmerican Hospital Self Insurance Trust 1401 E State Street Rockford IL 61104 366652702 Hospital Malpractice Trust VT 501(c)(3) Line 12a SwedishAmerican Hospital 1 SwedishAmerican Health System Corporation 1401 E State Street Rockford IL 61104 363241458 Parent Corporation to Manage and Direct Activities of Entities IL 501(c)(3) Line 12a Regional Division Inc 1 Quartz Health Plan Corporation 840 Carolina Street Sauk City WI 53583 391807071 Health Insurance WI 501(c)(4) University Health Care Inc 1 Quartz Health Plan MN Corporation 840 Carolina Street Sauk City WI 53583 452633920 Health Insurance WI 501(c)(4) Quartz Health Plan Corporation 1 Isthmus Project Inc 600 Highland Avenue Madison WI 53792 832278676 Research and Innovation WI 501(c)(3) Line 12a University of WI Hospitals and Clinics Authority 1 Madison Medical Center LLP 7974 UW Health Court Middleton WI 53562 391329429 Specialized Medical Center WI N/A Chartwell Wisconsin Enterprises LLC 2241 Pinehurst Drive Middleton WI 53562 391796267 Infusion Therapy WI N/A Sixth Street Medical LLC 7974 UW Health Court Middleton WI 53562 472705724 Lease and Rental Services WI N/A Meriter UW Physician Contracting Company LLC 202 S Park Street Madison WI 53715 391998819 Health Services WI N/A Three Rivers Partners LLC 1313 E State Street Rockford IL 61104 262231757 Information Technology Services IL N/A Northern Illinois Vein Clinic 2550 Charles Street Rockford IL 61108 201642329 Outpatient Health Services IL N/A SARI Insurance Company 76 St Paul Street Suite 500 Burlington VT 054014477 030308753 Captive Insurance Company VT N/A C 1 State & Charles Inc 1313 E State Street Rockford IL 61104 363321193 Holding Company IL N/A C 1 SwedishAmerican Health Management Corp 1401 E State Street Rockford IL 61104 363246511 Management Services IL N/A C 1 Physician's Care Network 1313 E State Street Rockford IL 61104 363455791 Health Services IL N/A C 1 Quartz Health Benefit Plans Corporation 840 Carolina Street Sauk City WI 53583 391450766 Health Maintenance Organization WI N/A C 1 Health Professionals of Wisconsin 301 S Westfield Road Madison WI 53717 391806711 Real Estate WI N/A C 1 Quartz Holding Company 840 Carolina Street Sauk City WI 53583 821728929 Holding Company WI N/A C 1 Quartz Health Solutions Inc 840 Carolina Street Sauk City WI 53583 465710709 Insurance WI N/A C 1 Quartz Health Insurance Corporation 840 Carolina Street Sauk City WI 53583 391565691 Health Maintenance Organization WI N/A C 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0 0