2022-05-13T13:33:37-05:00 2021-06-30 470617373 COMMONSPIRIT HEALTH 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 990 2020-07-01 450231183 MERCY MEDICAL CENTER MERC 7017747400 1301 15TH AVE W WILLISTON ND 58801 JOSEPH RUARK CFO 7017747400 2022-05-13 1 JOSEPH RUARK PAMELA KROHN P01210500 3032989100 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z CHI ST ALEXIUS HEALTH WILLISTON MED DAN BJERKNES 1301 15TH AVE W WILLISTON ND 58801 89625868 0 0928 X HTTPS://WWW.CHISTALEXIUSHEALTH.ORG/LOCATIONS X 1920 ND MERCY MEDICAL CENTER IS A CRITICAL ACCESS HOSPITAL SERVING A LARGE GEOGRAPHICAL AREA. COMMUNITY BENEFITS INCLUDE: UNCOMPENSATED CARE, MEDICAL EDUCATION AND AWARENESS, SUPPORT SERVICES, AND COMMUNITY OUTREACH. 12 9 514 81 186666 0 4789677 4301673 82333944 82371163 43967 4067 3549589 2941423 90717177 89618326 20889 69 0 0 34189010 33336829 0 0 413255 53978375 53434931 88188274 86771829 2528903 2846497 138014231 152394066 80946965 92531714 57067266 59862352 AS AN AFFILIATE OF COMMONSPIRIT HEALTH, WE MAKE THE HEALING PRESENCE OF GOD KNOWN IN OUR WORLD BY IMPROVING THE HEALTH OF THE PEOPLE WE SERVE, ESPECIALLY THOSE WHO ARE VULNERABLE, WHILE WE ADVANCE SOCIAL JUSTICE FOR ALL. 0 0 74403083 69 82276663 SEE SCHEDULE H 74403083 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 0 0 514 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 12 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 0 1 0 0 ND X JOSEPH RUARK 7017747408 1301 15TH AVE WEST WILLISTON ND 58801 CLIFF ROBERTSON DIRECTOR/CSH SVP DIVISION OFFICER 1.00 50.00 X 0 2330702 46702 JEFFREY DROP DIRECTOR/CSH SVP DIVISION OFFICER 1.00 50.00 X 0 1263797 34793 JEANETTE WOJTALEWICZ DIRECTOR/CSH SVP DIVISION OFFICER 1.00 50.00 X 0 986312 50266 BRENNEN SMITH ORTHOPEDIST 10.00 30.00 X 118557 663233 43671 MATT GRIMSHAW FORMER EX-OFFICIO / MARKET PRESIDENT 0.00 45.00 X 0 681006 43267 KURT SCHLEY FORMER OFFICER 1.00 50.00 X 0 649227 65899 GREGORY BROWN MD PHYSICIAN 40.00 0.00 X 686273 0 21871 FAREED KADUM MD OB/GYN-SURGEON 40.00 0.00 X 647262 0 26511 KEVIN DAHMEN MD FORMER SECRETARY / TREASURER (7/19-10/19) 1.00 40.00 X 0 474992 54610 PEERAWUT DEEPRASERTKUL CARDIOLOGIST-NON-INVASIVE 40.00 0.00 X 482935 0 26322 ASHLEY LEMERE GENERAL SURGEON 40.00 0.00 X 465693 0 42808 MICHAEL CASSIDY MD DIRECTOR 1.00 40.00 X 0 457927 34854 TESSA MARBURGER MD DIRECTOR 40.00 3.00 X 402438 0 24833 DAN BJERKNES PRESIDENT & CEO 40.00 0.00 X 244929 0 54411 JOSEPH RUARK CFO/VP OF FINANCE 1.00 50.00 X 0 181057 34601 MICHAEL LEFOR CHAIR 1.00 3.00 X X 0 0 0 PATRICK SOGARD VICE CHAIR 1.00 3.00 X X 0 0 0 JULIE TRAYNOR SECRETARY / TREASURER 1.00 3.00 X X 0 0 0 SR MARY RUTH HUHN DIRECTOR 1.00 3.00 X 0 0 0 CORRY KENNER DIRECTOR 1.00 3.00 X 0 0 0 MIKE MURPHY DIRECTOR 1.00 3.00 X 0 0 0 KIRK SCHOEPP DIRECTOR 1.00 3.00 X 0 0 0 KRISTI SCHWARTZ DIRECTOR 1.00 3.00 X 0 0 0 CURTIS WIESZ DIRECTOR 1.00 3.00 X 0 0 0 3048087 7688253 605419 50 1 1 0 CEP AMERICA LLC DBA VITUITY 2100 POWELL ST SUITE 400 EMERYVILLE CA 94608 STAFFING 1653448 COMPHEALTH 7259 S BINGHAM JCT BLVD MIDVALE UT 84047 STAFFING 1318853 HEALTH CAROUSEL LLC 3805 EDWARDS RD 700 CINCINNATI OH 45209 WORKFORCE SOLUTIONS 1252090 AMN HEALTHCARE 12400 HIGH BLUFF DRIVE SAN DIEGO CA 92130 HEALTHCARE CONSULTING 1190036 RECRUITING RESOURCES 11500 W OLYMPIC BLVD SUITE 400 LOS ANGELES CA 90064 MEDICAL STAFFING SERVICES 1010263 21 1227863 2881273 192537 4301673 PATIENT SERVICES 900099 82036442 82036442 0 0 RENTAL INCOME 900099 283313 188813 94500 0 INTERCOMPANY TRANSACTIONS 900099 51408 51408 0 0 82371163 11609 11609 7542 -7542 -7542 -7542 PHARMACY SERVICES 446110 1989203 1989203 MEDICAL SERVICES 900099 849808 849808 PRINTING & NUTRITION 900099 92166 92166 10246 10246 2941423 89618326 82276663 186666 2853324 X 69 69 681387 647317 34070 26344811 25027571 1041540 275700 1340849 1273806 52782 14261 3035888 2884094 120758 31036 1933894 1837200 77356 19338 145854 145854 165 157 8 8679 8679 21942313 20571131 1371182 110138 49562 60576 896515 860655 26895 8965 4509808 4509808 2180237 1744190 436047 333997 297257 33400 3340 3912 2660 1213 39 250514 250514 3598548 3598548 4102994 4020934 82060 484428 135640 348788 MEDICAL SUPPLIES 13511640 13511640 REPAIRS AND MAINTENANCE 783431 783431 MISCELLANEOUS EXPENSES 167021 160340 6681 RECRUITMENT AND RELOCAT 148173 148173 256564 246304 10260 86771829 74403083 11955491 413255 5364 6197 15301009 9668984 15033893 14638563 3814 166631 214179 3202063 4659485 218676 231211 94008691 54761473 39246097 39247218 64836684 83728229 138014231 152394066 15238131 15407189 3075777 254595 62633057 76869930 80946965 92531714 X 57067266 59862352 57067266 59862352 138014231 152394066 X 2846497 54831 -106242 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 8679 0 0 0 8679 0 PART II-B, LINE 1: AMERICAN HOSPITAL ASSOCIATION - $1,370 CATHOLIC HEALTH ASSOCIATION - $729 NORTH DAKOTA HEALTHCARE ASSOCIATION - $6,580 328028 328028 48099695 24527003 23572692 1795757 1110095 685662 41758890 28205804 13553086 2026321 918571 1107750 39247218 INTERCOMPANY RECEIVABLES 71224497 INVESTMENTS IN UNCONSOLIDATED ORGS 360000 DEPOSITS 65138 LEASE 12078594 83728229 INTERCOMPANY PAYABLES 60818747 OTHER LIABILITIES 1411 CHI DEBT 3938793 LEASE LIABILITY 12110979 76869930 X PART X, LINE 2: MERCY MEDICAL CENTER'S FINANCIAL INFORMATION IS INCLUDED IN COMMONSPIRIT HEALTH'S CONSOLIDATED AUDITED FINANCIAL STATEMENTS, WHICH INCLUDES THE FOLLOWING DISCLOSURE: COMMONSPIRIT REVIEWS ITS TAX POSITIONS QUARTERLY AND HAS DETERMINED THAT THERE ARE NO MATERIAL UNCERTAIN TAX POSITIONS THAT REQUIRE RECOGNITION IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. 1 1 X 1 X 300.000000000000 1 X 1 1 1 0 1 1 1354 2403909 2403909 0.02770 1598029 1598029 0.01840 1354 4001938 4001938 0.04610 5 5578 420021 420021 0.00480 1 0 1195 1195 0.00000 0 0 0 6 5578 421216 421216 0.00480 6 6932 4423154 4423154 0.05090 1 0 120 120 0.00000 1 120 120 0.00000 1 8976268 11718912 17413115 -5694203 X 1 1 1 1 MERCY MEDICAL CENTER 1301 15TH AVE W WILLISTON ND 58801 HTTPS://WWW.CHISTALEXIUSHEALTH.ORG 5052A X X X X OP CLINICS (PSYCH, FAMILY PRACTICE, GENERAL SURGERY, ORTHO, PAIN MANAGEMENT) MERCY MEDICAL CENTER 1 0 0 1 X X X X X X X X X 18 1 0 1 1 X SEE PART V, PAGE 10 X 1 19 1 HTTPS://WWW.CHISTALEXIUSHEALTH.ORG/COMMUNITY-HEALTH-NEED-ASSESSMENTS 0 1 X 300.000000000000 300.000000000000 X X X X 1 1 X X X 1 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X X X X X X 1 X 0 X X X X 1 X 0 0 MERCY MEDICAL CENTER PART V, SECTION B, LINE 5: BEGINNING IN THE FALL OF 2018, THE HOSPITAL WORKED WITH REPRESENTATIVES FROM THE CENTER FOR RURAL HEALTH AT THE UND SCHOOL OF MEDICINE. WITH THEIR HELP WE ORGANIZED COMMUNITY STAKEHOLDER MEETINGS, ONE ON ONE INTERVIEWS, AND FOCUS GROUPS. THESE VARIOUS MEETINGS WERE COMPRISED OF PEOPLE FROM THE CITY OF WILLISTON, DISTRICT HEALTH, LOCAL BUSINESSES, NON-AFFILIATED PHYSICIANS, NON-AFFILIATED CLINIC MANAGERS, EMS, LAW ENFORCEMENT, PARKS AND REC, RETIRED/VOLUNTEERS, AND HOSPITAL LEADERS. IN ADDITION, WE CONDUCTED A COMMUNITY SURVEY PROVIDING PRINT AND ONLINE FORMS OF THE SURVEY. MERCY MEDICAL CENTER PART V, SECTION B, LINE 6B: UPPER MISSOURI DISTRICT HEALTH MERCY MEDICAL CENTER PART V, SECTION B, LINE 11: TOP FOUR NEEDS FROM THE CHNA: I. ABILITY TO GET APPOINTMENTS FOR HEALTH SERVICES WITHIN 48 HOURS; II. RETAINING PRIMARY CARE PROVIDERS; III. PROVIDING EXTRA HOURS FOR APPOINTMENTS, SUCH AS EVENINGS AND WEEKENDS; AND IV. INCREASING CHILD DAYCARE SERVICES. THE ABILITY TO GET A PRIMARY CARE APPOINTMENT AND HAVING EXTENDED HOURS FOR APPOINTMENTS WERE TWO CONCERNS OUTLINED IN OUR 2019 COMMUNITY HEALTH NEEDS ASSESSMENT. IN NOVEMBER 2019 WE BEGAN "NEED CARE NOW" APPOINTMENTS. IN SEPTEMBER 2020 WE EXTENDED OUR PRIMARY CLINIC HOURS TO 7:00AM-5:30PM. THE LATEST EXPANSION OF OUR PRIMARY CLINIC WAS ESTABLISHING A WALK-IN CLINIC. OUR WALK-IN CLINIC BEGAN ON 4-12-21.THE VOLUME IN THE WALK-IN CLINIC HAS BEEN CONSISTENTLY HIGH SINCE THE DOORS OPENED IN APRIL 2021. IN THE UPCOMING WEEKS WE WILL BE MOVING THE CLINIC FROM ITS CURRENT LOCATION TO THE SPACE CURRENTLY OCCUPIED BY THE RESIDENCY CLINIC AND WOMEN'S HEALTH CLINIC. THERE ARE MANY MOVING PIECES TO THIS, BUT WE FEEL THAT IT IS THE BEST FOR THE PATIENT EXPERIENCE AND THOSE THAT WORK IN THE WALK-IN CLINIC.WE HAVE RECRUITED TWO ADDITIONAL NPS WHO WILL BE DEDICATED TO THE WALK-IN CLINIC. IN THE LAST TWO YEARS, WE HIRED 3 FPS AND HAVE ADDED ORTHOPEDIC SERVICES AGAIN. THE CAPITAL PROJECT TO RENOVATE THE SISTERS OF MERCY HOUSE AND BUILD A DAYCARE WAS APPROVED ON NOVEMBER 23. WE ARE NOW WORKING WITH OUR NATIONAL REAL ESTATE TEAM, AND WE HOPE TO START RENOVATIONS IN THE NEW YEAR. MERCY MEDICAL CENTER PART V, SECTION B, LINE 13H: THE PATIENT MUST HAVE A MINIMUM ACCOUNT BALANCE OF THIRTY-FIVE DOLLARS ($35.00) WITH THE CHI HOSPITAL ORGANIZATION. MULTIPLE ACCOUNT BALANCES MAY BE COMBINED TO REACH THIS AMOUNT. PATIENTS/GUARANTORS WITH BALANCES BELOW THIRTY-FIVE DOLLARS ($35) MAY CONTACT A FINANCIAL COUNSELOR TO MAKE MONTHLY INSTALLMENT PAYMENT ARRANGEMENTS. THE PATIENT MUST SUBMIT A COMPLETED FINANCIAL ASSISTANCE APPLICATION. PATIENT COOPERATION STANDARDS - A PATIENT MUST EXHAUST ALL OTHER PAYMENT OPTIONS, INCLUDING PRIVATE COVERAGE, FEDERAL, STATE AND LOCAL MEDICAL ASSISTANCE PROGRAMS, AND OTHER FORMS OF ASSISTANCE PROVIDED BY THIRD-PARTIES PRIOR TO BEING APPROVED. AN APPLICANT FOR FINANCIAL ASSISTANCE IS RESPONSIBLE FOR APPLYING TO PUBLIC PROGRAMS FOR AVAILABLE COVERAGE. HE OR SHE IS ALSO EXPECTED TO PURSUE PUBLIC OR PRIVATE HEALTH INSURANCE PAYMENT OPTIONS FOR CARE PROVIDED BY A CHI HOSPITAL ORGANIZATION WITHIN A HOSPITAL FACILITY. A PATIENT'S AND, IF APPLICABLE, ANY GUARANTOR'S COOPERATION IN APPLYING FOR APPLICABLE PROGRAMS AND IDENTIFIABLE FUNDING SOURCES, INCLUDING COBRA COVERAGE (A FEDERAL LAW ALLOWING FOR A TIME-LIMITED EXTENSION OF EMPLOYEE HEALTHCARE BENEFITS), SHALL BE REQUIRED. IF A HOSPITAL FACILITY DETERMINES THAT COBRA COVERAGE IS POTENTIALLY AVAILABLE, AND THAT A PATIENT IS NOT A MEDICARE OR MEDICAID BENEFICIARY, THE PATIENT OR GUARANTOR SHALL PROVIDE THE HOSPITAL FACILITY WITH INFORMATION NECESSARY TO DETERMINE THE MONTHLY COBRA PREMIUM FOR SUCH PATIENT, AND SHALL COOPERATE WITH HOSPITAL FACILITY STAFF TO DETERMINE WHETHER HE OR SHE QUALIFIES FOR HOSPITAL FACILITY COBRA PREMIUM ASSISTANCE, WHICH MAY BE OFFERED FOR A LIMITED TIME TO ASSIST IN SECURING INSURANCE COVERAGE. A HOSPITAL FACILITY SHALL MAKE AFFIRMATIVE EFFORTS TO HELP A PATIENT OR PATIENT'S GUARANTOR APPLY FOR PUBLIC AND PRIVATE PROGRAMS. PART V, SECTION B, LINE 3E: THE SIGNIFICANT HEALTH NEEDS ARE A PRIORITIZED DESCRIPTION OF THE COMMUNITY'S SIGNIFICANT HEALTH NEEDS IDENTIFIED THROUGH THE CHNA. SCHEDULE H, PART V, SECTION B, LINE 7A HTTPS://WWW.CHISTALEXIUSHEALTH.ORG/COMMUNITY-HEALTH-NEED-ASSESSMENTS SCHEDULE H, PART V, SECTION B, LINE 16A HTTPS://WWW.CHISTALEXIUSHEALTH.ORG/PATIENTS-VISITORS/OUR-PATIENTS/FINANCIAL-ASSISTANCE SCHEDULE H, PART V, SECTION B, LINE 16B HTTPS://WWW.CHISTALEXIUSHEALTH.ORG/PATIENTS-VISITORS/OUR-PATIENTS/FINANCIAL-ASSISTANCE SCHEDULE H, PART V, SECTION B, LINE 16C HTTPS://WWW.CHISTALEXIUSHEALTH.ORG/PATIENTS-VISITORS/OUR-PATIENTS/FINANCIAL-ASSISTANCE 3 1 - CRAVEN-HAGAN CLINIC 1213 15TH AVENUE WEST WILLISTON ND 58801 MEDICAL CLINIC 2 - UROLOGY CLINIC 1219 KNOLL STREET WILLISTON ND 58801 MEDICAL CLINIC 3 - SPECIALTY CLINIC 1500 14TH ST WEST SUITE 300 WILLISTON ND 58801 MEDICAL CLINIC PART I, LINE 3C: UNLESS ELIGIBLE FOR PRESUMPTIVE FINANCIAL ASSISTANCE, THE FOLLOWING ELIGIBILITY CRITERIA MUST BE MET IN ORDER FOR A PATIENT TO QUALIFY FOR FINANCIAL ASSISTANCE: THE PATIENT MUST HAVE A MINIMUM ACCOUNT BALANCE OF THIRTY-FIVE DOLLARS ($35.00) WITH THE CHI HOSPITAL ORGANIZATION. MULTIPLE ACCOUNT BALANCES MAY BE COMBINED TO REACH THIS AMOUNT. PATIENTS/GUARANTORS WITH BALANCES BELOW THIRTY-FIVE DOLLARS ($35) MAY CONTACT A FINANCIAL COUNSELOR TO MAKE MONTHLY INSTALLMENT PAYMENT ARRANGEMENTS. THE PATIENT'S FAMILY INCOME MUST BE AT OR BELOW 300% OF THE FPG. THE PATIENT MUST COMPLY WITH PATIENT COOPERATION STANDARDS AS DESCRIBED [IN THE FAP]. THE PATIENT MUST SUBMIT A COMPLETED FINANCIAL ASSISTANCE APPLICATION. FOR PATIENTS AND GUARANTORS WHO ARE UNABLE TO PROVIDE REQUIRED DOCUMENTATION, A HOSPITAL FACILITY MAY GRANT PRESUMPTIVE FINANCIAL ASSISTANCE BASED ON INFORMATION OBTAINED FROM OTHER RESOURCES. IN PARTICULAR, PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED ON THE BASIS OF INDIVIDUAL LIFE CIRCUMSTANCES THAT MAY INCLUDE: RECIPIENT OF STATE-FUNDED PRESCRIPTION PROGRAMS; HOMELESS OR ONE WHO RECEIVED CARE FROM A HOMELESS CLINIC; PARTICIPATION IN WOMEN, INFANTS AND CHILDREN PROGRAMS (WIC); FOOD STAMP ELIGIBILITY; SUBSIDIZED SCHOOL LUNCH PROGRAM ELIGIBILITY; ELIGIBILITY FOR OTHER STATE OR LOCAL ASSISTANCE PROGRAMS (E.G., MEDICAID SPEND-DOWN); LOW INCOME/SUBSIDIZED HOUSING IS PROVIDED AS A VALID ADDRESS; OR PATIENT IS DECEASED WITH NO KNOWN ESTATE. PART I, LINE 7: THE ORGANIZATION'S COST ACCOUNTING SYSTEM WAS USED TO REPORT FINANCIAL ASSISTANCE AND COMMUNITY BENEFITS IN PART I, LINE 7. THE ORGANIZATION'S COST ACCOUNTING SYSTEM ADDRESSES ALL OF THE PATIENTS SERVED BY MERCY MEDICAL CENTER. PART III, LINE 2: THE ORGANIZATION HAS REPORTED BAD DEBT EXPENSE AT GROSS CHARGES WRITTEN OFF. THE ORGANIZATION'S BAD DEBT EXPENSE REPRESENTS AMOUNTS BILLED TO PATIENTS THAT WAS DEEMED UNCOLLECTIBLE AND DOES NOT INCLUDE ANY CHARGES THAT WERE ULTIMATELY REIMBURSED OR DISCOUNTED. PATIENT DISCOUNTS ARE RECORDED IN CONTRACTUAL ALLOWANCE OR FINANCIAL ASSISTANCE, AS APPROPRIATE, AS AN OFFSET TO GROSS REVENUE AND ARE NOT INCLUDED IN BAD DEBT EXPENSE. PART III, LINE 3: MERCY MEDICAL CENTER DOES NOT BELIEVE THAT ANY PORTION OF BAD DEBT EXPENSE COULD REASONABLY BE ATTRIBUTED TO PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE SINCE AMOUNTS DUE FROM THOSE INDIVIDUALS' ACCOUNTS WILL BE RECLASSIFIED FROM BAD DEBT EXPENSE TO CHARITY CARE WITHIN 30 DAYS FOLLOWING THE DATE THAT THE PATIENT IS DETERMINED TO QUALIFY FOR CHARITY CARE. PART III, LINE 4: MERCY MEDICAL CENTER DOES NOT ISSUE SEPARATE COMPANY AUDITED FINANCIAL STATEMENTS. HOWEVER, THE ORGANIZATION IS INCLUDED IN THE CONSOLIDATED FINANCIAL STATEMENTS OF COMMONSPIRIT HEALTH. THE CONSOLIDATED FOOTNOTE READS AS FOLLOWS:COMMONSPIRIT RELIES ON THE RESULTS OF DETAILED REVIEWS OF HISTORICAL WRITE-OFFS AND COLLECTIONS IN ESTIMATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE. UPDATES TO THE HINDSIGHT ANALYSIS ARE PERFORMED AT LEAST QUARTERLY USING PRIMARILY A ROLLING EIGHTEEN-MONTH COLLECTION HISTORY AND WRITE-OFF DATA. SUBSEQUENT CHANGES TO ESTIMATES OF THE TRANSACTION PRICE ARE GENERALLY RECORDED AS ADJUSTMENTS TO NET PATIENT REVENUE IN THE PERIOD OF THE CHANGE.SUBSEQUENT CHANGES THAT ARE DETERMINED TO BE THE RESULT OF AN ADVERSE CHANGE IN A THIRD-PARTY PAYOR'S ABILITY TO PAY ARE RECORDED AS BAD DEBT EXPENSE IN PURCHASED SERVICES AND OTHER IN THE ACCOMPANYING CONSOLIDATED STATEMENTS OF OPERATIONS AND CHANGES IN NET ASSETS. BAD DEBT EXPENSE FOR 2021 AND 2020 WAS NOT SIGNIFICANT. PART III, LINE 8: COMMONSPIRIT HEALTH HOSPITALS PREPARE MEDICARE COST REPORTS IN A MANNER THAT COMPORTS WITH PROVIDER REIMBURSEMENT MANUAL (PRM) 15-1 AND PRM 15-2 CHAPTER 40 (TRANSMITTAL 13). AS SUCH, THE FOLLOWING LANGUAGE PER PRM 15-1 DESCRIBES THE COMPUTATION OF COSTS PER THE MEDICARE COST REPORT: TOTAL ALLOWABLE COSTS OF A PROVIDER ARE APPORTIONED BETWEEN PROGRAM BENEFICIARIES AND OTHER PATIENTS SO THAT THE SHARE BORNE BY THE PROGRAM IS BASED UPON ACTUAL SERVICES RECEIVED BY PROGRAM BENEFICIARIES. THE RATIO OF COVERED BENEFICIARY CHARGES TO TOTAL PATIENT CHARGES FOR THE SERVICES OF EACH ANCILLARY DEPARTMENT IS APPLIED TO THE COST OF THE DEPARTMENT. ADDED TO THIS AMOUNT IS THE COST OF ROUTINE SERVICES FOR PROGRAM BENEFICIARIES, DETERMINED ON THE BASIS OF A SEPARATE AVERAGE COST PER DIEM FOR ALL PATIENTS FOR GENERAL ROUTINE PATIENT CARE AREAS. ANOTHER FACTOR CONSIDERED IS A SEPARATE AVERAGE COST PER DIEM FOR EACH INTENSIVE CARE UNIT, CORONARY CARE UNIT, AND OTHER SPECIAL CARE INPATIENT HOSPITAL UNITS. COMMONSPIRIT HEALTH AND ITS SUBORDINATE CORPORATIONS BELIEVE THAT THE ENTIRE MEDICARE SHORTFALL FOR THE CONSOLIDATED ENTITIES, CONSTITUTES COMMUNITY BENEFIT. THE IRS COMMUNITY BENEFIT STANDARD INCLUDES THE PROVISION OF CARE TO THE ELDERLY AND MEDICARE PATIENTS. MEDICARE SHORTFALLS MUST BE ABSORBED BY COMMONSPIRIT HEALTH HOSPITALS IN ORDER TO CONTINUE TREATING THE ELDERLY IN OUR COMMUNITIES. THE HOSPITALS PROVIDE CARE REGARDLESS OF THIS SHORTFALL AND THEREBY RELIEVE THE FEDERAL GOVERNMENT OF THE BURDEN OF PAYING THE FULL COST FOR MEDICARE BENEFICIARIES. MERCY MEDICAL CENTER'S SHORTFALL, AS REPORTED ON PART III, SECTION B, LINE 7, OF $5,694,203 REPRESENTS THE FILING ORGANIZATION'S MEDICARE COST REPORTS. PART III, LINE 9B: THE ORGANIZATION'S BILLING AND COLLECTIONS POLICY APPLIES TO ALL INDIVIDUALS PRESENTING FOR EMERGENCY OR OTHER MEDICALLY NECESSARY CARE. THE POLICY CONTAINS PROVISIONS FOR COLLECTING AMOUNTS DUE FROM THOSE PATIENTS WHO THE ORGANIZATION KNOWS TO QUALIFY FOR FINANCIAL ASSISTANCE EITHER THROUGH THE TRADITIONAL FINANCIAL ASSISTANCE APPLICATION PROCESS OR THROUGH PRESUMPTIVE ELIGIBILITY PROCESSES. BEFORE ENGAGING IN EXTRAORDINARY COLLECTION ACTIONS (ECAS) TO OBTAIN PAYMENT FOR EMCARE, HOSPITAL FACILITIES MUST MAKE REASONABLE EFFORTS THROUGH ITS BILLING AND COLLECTIONS PROCESSES, PURSUANT TO TREAS. REG. 1.501(R)-6(C), TO DETERMINE WHETHER AN INDIVIDUAL IS ELIGIBLE FOR FINANCIAL ASSISTANCE. IN NO EVENT WILL AN ECA BE INITIATED PRIOR TO 120 DAYS FROM THE DATE THE FACILITY PROVIDES THE FIRST POST-DISCHARGE BILLING STATEMENT (I.E., DURING THE NOTIFICATION PERIOD) UNLESS ALL REASONABLE EFFORTS HAVE BEEN MADE.HOSPITAL FACILITIES WILL NOT REFER ACCOUNTS FOR COLLECTION WHERE THE PATIENT HAS INITIALLY APPLIED FOR FINANCIAL ASSISTANCE, AND THE HOSPITAL FACILITY HAS NOT YET MADE REASONABLE EFFORTS WITH RESPECT TO THE ACCOUNT. FOR PATIENTS AND GUARANTORS WHO ARE UNABLE TO PROVIDE REQUIRED DOCUMENTATION, A HOSPITAL FACILITY MAY GRANT PRESUMPTIVE FINANCIAL ASSISTANCE BASED ON INFORMATION OBTAINED FROM OTHER RESOURCES. PATIENTS WHO QUALIFY FOR MEDICAID ARE PRESUMED TO QUALIFY FOR FULL CHARITY WRITE OFF. ANY CHARGES FOR DAYS OR SERVICES WRITTEN OFF (EXCLUDING MEDICAID DENIALS RELATED TO TIMELINESS OF BILLING, INSUFFICIENT MEDICAL RECORD DOCUMENTATION, MISSING INVOICES, AUTHORIZATION, OR ELIGIBILITY ISSUES) AS A RESULT OF A MEDICAID ARE BOOKED AS CHARITY.SOME MEDICAID PLANS OFFER COVERAGE FOR A LIMITED OR RESTRICTED LIST OF SERVICES. IF A PATIENT IS ELIGIBLE FOR MEDICAID, ANY CHARGES FOR DAYS OR SERVICES NOT COVERED BY THE PATIENT'S COVERAGE MAY BE WRITTEN OFF TO CHARITY WITHOUT A COMPLETED APPLICATION. THIS DOES NOT INCLUDE ANY SHARE OF COST (SOC) OR OTHER PATIENT COST-SHARING AMOUNTS SUCH AS DEDUCTIBLES OR COPAYMENTS, AS SUCH COSTS ARE DETERMINED BY THE STATE TO BE AN AMOUNT THAT THE PATIENT MUST PAY BEFORE THE PATIENT IS ELIGIBLE FOR MEDICAID. HEALTH AND HUMAN SERVICES (HSS) USES THE TERM "SPEND DOWN" INSTEAD OF SHARE OF COST.ALL COLLECTION ACTIVITIES CONDUCTED BY THE FACILITY, A DESIGNATED SUPPLIER, OR ITS THIRD-PARTY COLLECTION AGENTS WILL BE IN CONFORMANCE WITH ALL FEDERAL AND STATE LAWS GOVERNING DEBT COLLECTION PRACTICES. ALL THIRD-PARTY AGREEMENTS GOVERNING COLLECTION AND RECOVERY ACTIVITIES MUST INCLUDE A PROVISION REQUIRING COMPLIANCE WITH THE HOSPITAL FACILITIES' FINANCIAL ASSISTANCE AND BILLING AND COLLECTIONS POLICY AND INDEMNIFICATION FOR FAILURES AS A RESULT OF ITS NONCOMPLIANCE. THIS INCLUDES, BUT IS NOT LIMITED TO, AGREEMENTS BETWEEN THIRD PARTIES WHO SUBSEQUENTLY SELL OR REFER DEBT OF THE HOSPITAL FACILITY. PART VI, LINE 2: WE HAVE GOOD RELATIONSHIPS WITH CITY GOVERNMENT, BUSINESS, CHURCH, AND PUBLIC HEALTH LEADERS IN THE COMMUNITY. THOSE RELATIONSHIPS, ALONG WITH OUR OWN HISTORY OF DOING CHNAS GIVES US A PRETTY ACCURATE VIEW OF OUR HEALTH NEEDS. NOT MENTIONED IN THE DISCUSSION ABOVE ARE TWO NEEDS THAT COME UP IN ANY DISCUSSION ABOUT HEALTHCARE IN WILLISTON, ND: MENTAL HEALTH SERVICES AND ADDICTION TREATMENT. THESE ARE PERENNIAL CHNA TOP CONCERNS AND WERE IN THE 2019 SURVEY, TOO. OVER AND OVER AGAIN, HOWEVER, WE HAVE BEEN UNSUCCESSFUL IN ATTRACTING PARTNERS, PROVIDERS, OR EVEN CONTRACTORS TO PROVIDE THESE SERVICES (OTHER THAN TELEHEALTH). DISCUSSIONS WITH PROVIDERS, CITY AND COUNTY LEADERS, AND OTHER ORGANIZATIONS CONTINUE TO STALL WHEN CONFRONTING THE ISSUE OF FUNDING THESE TYPES OF SERVICES. PART VI, LINE 3: NOTIFICATION ABOUT THE AVAILABILITY OF FINANCIAL ASSISTANCE FROM CHI HOSPITAL ORGANIZATIONS SHALL BE DISSEMINATED BY VARIOUS MEANS, WHICH MAY INCLUDE, BUT NOT BE LIMITED TO: -CONSPICUOUS PUBLICATION OF NOTICES IN PATIENT BILLS; -NOTICES POSTED IN EMERGENCY ROOMS, URGENT CARE CENTERS, ADMITTING/REGISTRATION DEPARTMENTS, BUSINESS OFFICES, AND AT OTHER PUBLIC PLACES AS A HOSPITAL FACILITY MAY ELECT; AND-PUBLICATION OF A SUMMARY OF THIS POLICY ON THE HOSPITAL FACILITY'S WEBSITE AND AT OTHER PLACES WITHIN THE COMMUNITIES SERVED BY THE HOSPITAL FACILITY AS IT MAY ELECT. SUCH NOTICES AND SUMMARY INFORMATION SHALL INCLUDE A CONTACT NUMBER AND SHALL BE PROVIDED IN ENGLISH, SPANISH, AND OTHER PRIMARY LANGUAGES SPOKEN BY THE POPULATION SERVED BY AN INDIVIDUAL HOSPITAL FACILITY, AS APPLICABLE. REFERRAL OF PATIENTS FOR FINANCIAL ASSISTANCE MAY BE MADE BY ANY MEMBER OF THE CHI HOSPITAL ORGANIZATION NON-MEDICAL OR MEDICAL STAFF, INCLUDING PHYSICIANS, NURSES, FINANCIAL COUNSELORS, SOCIAL WORKERS, CASE MANAGERS, CHAPLAINS, AND RELIGIOUS SPONSORS. A REQUEST FOR ASSISTANCE MAY BE MADE BY THE PATIENT OR A FAMILY MEMBER, CLOSE FRIEND, OR ASSOCIATE OF THE PATIENT, SUBJECT TO APPLICABLE PRIVACY LAWS.IN ADDITION, HOSPITAL REGISTRATION CLERKS ARE TRAINED TO PROVIDE CONSULTATION TO THOSE WHO HAVE NO INSURANCE OR POTENTIALLY INADEQUATE INSURANCE CONCERNING THEIR FINANCIAL OPTIONS INCLUDING APPLICATION FOR MEDICAID AND FOR ASSISTANCE UNDER THE FINANCIAL ASSISTANCE POLICY. COUNSELORS ASSIST MEDICARE ELIGIBLE PATIENTS IN ENROLLMENT BY PROVIDING REFERRALS TO THE APPROPRIATE GOVERNMENT AGENCIES. ONCE IT IS DETERMINED THAT THE PATIENT DOES NOT QUALIFY FOR ANY THIRD PARTY FUNDING, THE PATIENT IS VERBALLY NOTIFIED ABOUT THE EXISTENCE OF FINANCIAL ASSISTANCE APPLICATION AND ADDITIONAL SCREENING TAKES PLACE BY A HOSPITAL EMPLOYEE TO DETERMINE IF THE PATIENT IS ELIGIBLE FOR CHARITY SERVICE PRIOR TO DISCHARGE. UPON REGISTRATION (AND ONCE ALL EMTALA REQUIREMENTS ARE MET), PATIENTS WHO ARE IDENTIFIED AS UNINSURED (AND NOT COVERED BY MEDICARE OR MEDICAID) ARE PROVIDED WITH A PACKET OF INFORMATION THAT ADDRESSES THE FINANCIAL ASSISTANCE POLICY, THE PLAIN LANGUAGE SUMMARY OF THAT POLICY, AND AN APPLICATION FOR ASSISTANCE. HOSPITAL REGISTRATION CLERKS READ THE ORGANIZATION'S MEDICAL ASSISTANCE POLICY TO THOSE WHO APPEAR TO BE INCAPABLE OF READING, AND PROVIDE TRANSLATORS FOR NON-ENGLISH-SPEAKING INDIVIDUALS. PATIENTS THAT HAVE BEEN DISCHARGED PRIOR TO CHARITY SCREENING, SUCH AS EMERGENCY ROOM PATIENTS, RECEIVE A WRITTEN NOTIFICATION OF POSSIBLE ELIGIBILITY FOR SERVICES. IF THE PATIENT IS DETERMINED NOT TO BE ELIGIBLE FOR GOVERNMENT ASSISTANCE, HE/SHE MAY NOTIFY THE HOSPITAL THAT THEY SEEK CHARITY ASSISTANCE. THE APPROPRIATE CHARITY FORM IS SENT TO THE PATIENT/GUARANTOR FOR COMPLETION AND THEN RETURNED TO THE HOSPITAL FOR EVALUATION AND QUALIFICATION. ONCE DETERMINATION OF ELIGIBILITY IS MADE, THE PATIENT IS SENT A NOTICE INFORMING HIM/HER IF THEY QUALIFY FOR FULL, PARTIAL, OR NO CHARITY CARE SERVICES.HOSPITAL FACILITIES MUST MAKE REASONABLE EFFORTS THROUGH ITS BILLING AND COLLECTIONS PROCESSES, PURSUANT TO TREAS. REG. 1.501(R)-6(C), TO DETERMINE WHETHER ANY INDIVIDUAL IS ELIGIBLE FOR FINANCIAL ASSISTANCE. PART VI, LINE 4: WILLISTON IS LOCATED IN THE NORTHWEST CORNER OF NORTH DAKOTA, JUST 60 MILES FROM THE CANADIAN BORDER AND 18 MILES FROM THE MONTANA BORDER. ITS ECONOMY IS BASED PRIMARILY ON THE OIL AND GAS INDUSTRY, AGRICULTURE, AND THE SERVICE SECTOR. IT IS THE SIXTH LARGEST CITY IN NORTH DAKOTA WITH A POPULATION OF 29,160 AS OF APRIL 1, 2020 (US CENSUS BUREAU). WILLISTON IS A SMALL TOWN WITH MANY AMENITIES THAT HAS EXPERIENCED AMAZING AND POSITIVE GROWTH IN THE LAST FEW YEARS. BRISK GROWTH HAS ALSO MADE IT A CITY WITH VIRTUALLY NO UNEMPLOYMENT AND A PER CAPITA INCOME OF $43,515. MEDIAN HOUSEHOLD INCOME IS ALMOST TWICE THAT AMOUNT.CURRENTLY, HOWEVER, WITH THE FALLING OF OIL PRICES, MANY OIL COMPANIES HAVE SLOWED DOWN AND LAID OFF WORKERS, THAT SLUMP AFFECTS HOUSING, AND SHOPPING CONCERNS IN THE AREA, TOO. MORE AND MORE FAMILIES ARE CHOOSING TO STAY HERE, HOWEVER; THOUGH THEIR CURRENT PROSPECTS HERE ARE WEAKER, THEY ARE BETTER THAN IN THE COMMUNITIES FROM WHICH THEY HAVE COME.IN ADDITION TO CHI ST. ALEXIUS HEALTH WMC, OTHER HOSPITALS ARE LOCATED IN THE SERVICE AREA. SPECIFICALLY, OTHER CRITICAL ACCESS HOSPITALS ARE LOCATED IN CROSBY, TIOGA, AND WATFORD CITY, NORTH DAKOTA, AS WELL AS POPLAR, SIDNEY, AND WOLF POINT, MONTANA. INDIAN HEALTH SERVICE ALSO MAINTAINS A SERVICE UNIT IN ROOSEVELT COUNTY, MONTANA, WITH FACILITIES IN POPLAR AND WOLF POINT.OTHER HEALTHCARE FACILITIES AND SERVICES IN THE NORTH DAKOTA PORTION OF THE AREA INCLUDE, A 168-BED NURSING HOME IN WILLISTON, A 19-BED BASIC CARE AND REHABILITATION CENTER IN WILLISTON, A 71 BED BASIC CARE FACILITY IN WILLISTON, A 42-BED NURSING HOME IN CROSBY, A 16-BED BASIC CARE FACILITY IN CROSBY, A 47-BED NURSING HOME IN WATFORD CITY (MCKENZIE COUNTY), A 9-BED BASIC CARE FACILITY IN WATFORD CITY, A 30-BED NURSING HOME IN TIOGA, AND SEVERAL INDEPENDENT LIVING COMMUNITIES FOR SENIORS. IN ADDITION TO THE PHARMACY AT CHI ST. ALEXIUS HEALTH WMC, THERE ARE FOUR RETAIL PHARMACIES IN WILLISTON; RETAIL PHARMACIES ARE ALSO LOCATED IN CROSBY, TIOGA, AND WATFORD CITY. ON THE MONTANA SIDE, OTHER HEALTHCARE FACILITIES INCLUDE A 40-BED ASSISTED LIVING FACILITY IN SIDNEY, AN EIGHT-BED ASSISTED LIVING FACILITY IN SAVAGE, A 93-BED LONG-TERM CARE FACILITY IN SIDNEY, AND A 60-BED LONG-TERM CARE FACILITY IN WOLF POINT.THIS MULTI-COUNTY REGION IS A MEDICALLY UNDERSERVED AREA AND OUR HOSPITAL BEING THE LARGEST IN THE REGION TREATS A SIGNIFICANT NUMBER OF MEDICAID PATIENTS, AND NATIVE AMERICAN PATIENTS THROUGH OUR MANY CLINICS OR THE HOSPITAL ITSELF. OUR HOMELESS POPULATION HAS DECREASED SIGNIFICANTLY SINCE 2014 AND NOW THIS GROUP IS MOSTLY SEASONAL AND GENERALLY TEMPORARY AS WE HAVE NO SHELTERS IN WILLISTON. WE STILL DO SEE A SIGNIFICANT NUMBER OF PEOPLE HOWEVER THAT STILL MEET "HOMELESS" CRITERIA. A FEW LIVE "ROUGH OR IN THEIR CARS, BUT MOST ARE STAYING PRECARIOUSLY WITH FRIENDS OR COWORKERS IN LESS THAN DESIRABLE CONDITIONS. PART VI, LINE 5: THE HOSPITAL DOES HAVE AN OPEN MEDICAL STAFF AND WE ARE PARTICIPANTS IN THE PHARMACY 340B PROGRAM - THE SAVINGS OF WHICH DIRECTLY IMPROVES PATIENT CARE. WE COLLABORATE WITH SEVERAL ACTIVE EDUCATION PROGRAMS IN PLACE INCLUDING WILLISTON STATE COLLEGE NURSING ASSOCIATE DEGREE PROGRAM AND THE UNIVERSITY OF NORTH DAKO TA FAMILY RESIDENCY PROGRAM. OUR ONCOLOGY CLINIC PROVIDES ASSISTANCE FOR GAS AND LODGING FOR PATIENTS THAT TRAVEL FROM OUTSIDE OUR IMMEDIATE SERVICE AREA. ADDITIONALLY, THE LAB SPONSORS A SEMI-ANNUAL BLOOD DRAW FOR AREA RESIDENTS. PRIMARY CARE ALSO SPONSORS ANNUAL FLU VACCINATIONS, AND ROUTINE BLOOD PRESSURE CLINICS. OUR HEALTHY COMMUNITY INITIATIVE IS A COLLABORATION WITH THE DISTRICT HEALTH UNIT - UTILIZING THEIR STAFF AND OURS TO COORDINATE WELL BABY PROGRAMS AND OTHERS ASSOCIATED WITH BUILDING HEALTHY FAMILIES. IN ADDITION, WE SPONSOR SEVERAL EDUCATION PROGRAMS IN CONJUNCTION WITH OUR VIOLENCE PREVENTION PROGRAM. PART VI, LINE 6: THE ORGANIZATION IS AFFILIATED WITH COMMONSPIRIT HEALTH. COMMONSPIRIT HEALTH WAS CREATED BY THE ALIGNMENT OF CATHOLIC HEALTH INITIATIVES AND DIGNITY HEALTH IN EARLY 2019. COMMONSPIRIT HEALTH, A NONPROFIT, FAITH-BASED HEALTH SYSTEM IS COMMITTED TO BUILDING HEALTHIER COMMUNITIES, ADVOCATING FOR THOSE WHO ARE POOR AND VULNERABLE, AND INNOVATING HOW AND WHERE HEALING CAN HAPPEN BOTH INSIDE ITS HOSPITALS AND OUT IN THE COMMUNITY. COMMONSPIRIT HEALTH OWNS AND OPERATES HEALTH CARE FACILITIES IN 21 STATES AND IS THE SOLE CORPORATE MEMBER (PARENT CORPORATION) OF OTHER PRIMARILY NONPROFIT CORPORATIONS THAT ARE EXEMPT FROM FEDERAL AND STATE INCOME TAXES. COMMONSPIRIT HEALTH IS COMPRISED OF MORE THAN 1,500 CARE SITES, CONSISTING OF 140 HOSPITALS, INCLUDING ACADEMIC HEALTH CENTERS, MAJOR TEACHING HOSPITALS, AND CRITICAL ACCESS FACILITIES, COMMUNITY HEALTH SERVICES ORGANIZATIONS, ACCREDITED NURSING COLLEGES, HOME HEALTH AGENCIES, LIVING COMMUNITIES, A MEDICAL FOUNDATION AND OTHER AFFILIATED MEDICAL GROUPS, AND OTHER FACILITIES AND SERVICES THAT SPAN THE INPATIENT AND OUTPATIENT CONTINUUM OF CARE. IN FISCAL YEAR 2021, COMMONSPIRIT HEALTH PROVIDED MORE THAN $2.5 BILLION IN FINANCIAL ASSISTANCE AND COMMUNITY BENEFIT FOR PROGRAMS AND SERVICES FOR THE POOR, FREE CLINICS, EDUCATION AND RESEARCH. FINANCIAL ASSISTANCE AND COMMUNITY BENEFIT TOTALED MORE THAN $5.1 BILLION WITH THE INCLUSION OF THE UNPAID COSTS OF MEDICARE. THE HEALTH SYSTEM, WHICH GENERATED OPERATING REVENUES OF $33.25 BILLION IN FISCAL YEAR 2021, HAS TOTAL ASSETS OF APPROXIMATELY $54.87 BILLION.COMMONSPIRIT HEALTH PROVIDES STRATEGIC PLANNING AND MANAGEMENT SERVICES AS WELL AS CENTRALIZED SERVICES FOR ITS DIVISIONS. THE PROVISION OF CENTRALIZED MANAGEMENT AND SHARED SERVICES INCLUDING AREAS SUCH AS ACCOUNTING, HUMAN RESOURCES, PAYROLL AND SUPPLY CHAIN PROVIDES ECONOMIES OF SCALE AND PURCHASING POWER TO THE DIVISIONS. THE COST SAVINGS ACHIEVED THROUGH COMMONSPIRIT HEALTH'S CENTRALIZATION ENABLE DIVISIONS TO DEDICATE ADDITIONAL RESOURCES TO HIGH-QUALITY HEALTH CARE AND COMMUNITY OUTREACH SERVICES TO THE MOST VULNERABLE MEMBERS OF OUR SOCIETY. PART VI, LINE 7, REPORTS FILED WITH STATES ND X X 0 1 0 0 0 0 0 0 0 CLIFF ROBERTSON DIRECTOR/CSH SVP DIVISION OFFICER 0 1011674 0 921351 0 397677 0 16975 0 29727 0 2377404 0 157178 JEFFREY DROP DIRECTOR/CSH SVP DIVISION OFFICER 0 692085 0 430582 0 141130 0 16844 0 17949 0 1298590 0 0 JEANETTE WOJTALEWICZ DIRECTOR/CSH SVP DIVISION OFFICER 0 553985 0 277663 0 154664 0 17649 0 32617 0 1036578 0 49946 BRENNEN SMITH ORTHOPEDIST 117165 583458 0 0 1392 79775 16975 0 2512 24184 138044 687417 0 0 MATT GRIMSHAW FORMER EX-OFFICIO / MARKET PRESIDENT 0 440703 0 211004 0 29299 0 16158 0 27109 0 724273 0 0 KURT SCHLEY FORMER OFFICER 0 425434 0 178127 0 45666 0 39610 0 26289 0 715126 0 39692 GREGORY BROWN MD PHYSICIAN 647300 0 2526 0 36447 0 12775 0 9096 0 708144 0 0 0 FAREED KADUM MD OB/GYN-SURGEON 635116 0 0 0 12146 0 16739 0 9772 0 673773 0 0 0 KEVIN DAHMEN MD FORMER SECRETARY / TREASURER (7/19-1 0 411065 0 61995 0 1932 0 25575 0 29035 0 529602 0 0 PEERAWUT DEEPRASERTKUL CARDIOLOGIST-NON-INVASIVE 470544 0 0 0 12391 0 14822 0 11500 0 509257 0 0 0 ASHLEY LEMERE GENERAL SURGEON 452908 0 0 0 12785 0 16975 0 25833 0 508501 0 0 0 MICHAEL CASSIDY MD DIRECTOR 0 426215 0 0 0 31712 0 17150 0 17704 0 492781 0 0 TESSA MARBURGER MD DIRECTOR 392301 0 0 0 10137 0 16544 0 8289 0 427271 0 0 0 DAN BJERKNES PRESIDENT & CEO 221080 0 23373 0 476 0 25273 0 29138 0 299340 0 0 0 JOSEPH RUARK CFO/VP OF FINANCE 0 171750 0 6900 0 2407 0 12315 0 22286 0 215658 0 0 PART I, LINE 4B LINE 4A FOR REPORTABLE INDIVIDUALS EMPLOYED PRIOR TO 2019, POST-TERMINATION PAYMENTS ARE ADDRESSED IN EXECUTIVE EMPLOYMENT AGREEMENTS FOR EMPLOYEES AT THE LEVEL OF VICE PRESIDENT AND ABOVE. THESE EMPLOYMENT AGREEMENTS REQUIRE THAT IN ORDER FOR THE EXECUTIVE TO RECEIVE POST-TERMINATION PAYMENTS, THESE INDIVIDUALS MUST EXECUTE A GENERAL RELEASE AND SETTLEMENT AGREEMENT. POST-TERMINATION PAYMENT ARRANGEMENTS ARE PERIODICALLY REVIEWED FOR OVERALL REASONABLENESS IN LIGHT OF THE EXECUTIVE'S OVERALL COMPENSATION PACKAGE. OFFICERS, KEY EMPLOYEES AND CERTAIN HIGHLY COMPENSATED EMPLOYEES WHO BEGAN EMPLOYMENT AFTER NOVEMBER 1ST OF 2019 ARE COVERED BY THE COMMONSPIRIT HEALTH EXECUTIVE SEVERANCE POLICY. THIS POLICY PROVIDES FOR SEVERANCE PAY WHICH VARIES BASED UPON THE EXECUTIVE'S POSITION LEVEL, IN THE EVENT OF A POSITION ELIMINATION OR OTHER QUALIFYING EVENT, IN ACCORDANCE WITH THE GUIDELINES OF THE EXECUTIVE SEVERANCE POLICY. AN EXECUTIVE'S WRITTEN EMPLOYMENT OR SEVERANCE AGREEMENT SHALL CONTROL WHERE THE SEVERANCE PAY AMOUNTS IN THE POLICY CONFLICT WITH THE EXECUTIVE'S WRITTEN EMPLOYMENT OR SEVERANCE AGREEMENT. IN ORDER FOR THE EXECUTIVE TO RECEIVE POST-TERMINATION PAYMENTS, THESE INDIVIDUALS MUST EXECUTE A GENERAL RELEASE AND SETTLEMENT OF CLAIMS. POST-TERMINATION PAYMENT ARRANGEMENTS ARE PERIODICALLY REVIEWED FOR OVERALL REASONABLENESS IN LIGHT OF THE EXECUTIVE'S OVERALL COMPENSATION PACKAGE. PART I, LINE 4B DURING THE 2020 CALENDAR YEAR, COMMONSPIRIT HEALTH ("COMMONSPIRIT") MAINTAINED A SUPPLEMENTAL NON-QUALIFIED DEFERRED COMPENSATION PLAN FOR DIVISION CEOS/PRESIDENTS AND OTHER DESIGNATED COMMONSPIRIT EXECUTIVES AT THE LEVEL OF SENIOR VICE PRESIDENT AND ABOVE. DURING 2020 THE FOLLOWING DISTRIBUTIONS WERE MADE BY COMMONSPIRIT FROM THE DEFERRED COMPENSATION PLAN: JEANETTE M WOJTALEWICZ $71,692; CLIFF ROBERTSON $186,901; KURT RONALD SCHLEY $39,903. DUE TO THE "SUPER" VESTING RULES UNDER COMMONSPIRIT'S DEFERRED COMPENSATION PLAN, PARTICIPANTS WHO HAVE MET CERTAIN REQUIREMENTS SUCH AS INVOLUNTARY TERMINATION WITHOUT CAUSE, AGE, AGE AND YEARS OF SERVICE, OR MORE THAN 5 YEARS OF PLAN PARTICIPATION ARE ELIGIBLE TO RECEIVE THEIR 2020 CONTRIBUTIONS IN CASH. THESE CASH PAYOUTS ARE INCLUDED IN THE PARTICIPANT'S REPORTABLE COMPENSATION IN COLUMN (III) OTHER REPORTABLE COMPENSATION ON SCHEDULE J PART II. DURING 2020, THE FOLLOWING PAYMENTS WERE MADE PURSUANT TO THE SUPER VESTING RULES: JEANETTE M WOJTALEWICZ $77,144; CLIFF ROBERTSON $195,187; JEFFREY DROP $113,534; AND MATT GRIMSHAW $29,299. FORM 990, PART VI, SECTION A, LINE 1 PURSUANT TO SECTION 8.6 OF THE BYLAWS OF MERCY MEDICAL CENTER, THE EXECUTIVE COMMITTEE IS COMPOSED OF THE BOARD CHAIR, THE BOARD VICE CHAIR, THE PRESIDENT AND CEO, EACH OF WHOM SHALL SERVE AS AN EX OFFICIO VOTING MEMBER OF THE EXECUTIVE COMMITTEE, AND TWO VOTING MEMBERS APPOINTED BY THE BOARD OF DIRECTORS. EACH INDIVIDUAL APPOINTED TO THE EXECUTIVE COMMITTEE SHALL SERVE FOR A TERM OF ONE YEAR OR UNTIL HIS OR HER SUCCESSOR IS DULY APPOINTED BY THE BOARD OF DIRECTORS. THE EXECUTIVE COMMITTEE SHALL CONSIST OF ONLY DIRECTORS OF THE CORPORATION. PURSUANT TO SECTION 8.1 OF THE CORPORATION'S BYLAWS, COMMITTEES, SUCH AS THE EXECUTIVE COMMITTEE, THAT ARE GRANTED THE AUTHORITY TO ACT ON BEHALF OF THE BOARD OF DIRECTORS MAY INCLUDE ONLY DIRECTORS OF THE CORPORATION. FURTHER, PURSUANT TO SECTION 8.6 OF THE CORPORATION'S BYLAWS, THE EXECUTIVE COMMITTEE HAS AND MAY EXERCISE SUCH POWERS AS MAY BE DELEGATED TO IT BY THE BOARD OF DIRECTORS. THE EXECUTIVE COMMITTEE ALSO POSSESSES THE POWER TO TRANSACT ROUTINE BUSINESS OF THE CORPORATION IN THE INTERIM PERIOD BETWEEN REGULARLY SCHEDULED MEETINGS OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 6 ACCORDING TO THE BYLAWS OF MERCY MEDICAL CENTER, THE ENTITY'S SOLE MEMBER IS COMMONSPIRIT HEALTH, A COLORADO NONPROFIT ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A ACCORDING TO THE ORGANIZATION'S BYLAWS, DIRECTORS SHALL BE APPOINTED OR REFUSED BY THE CORPORATE MEMBER. THE CORPORATE MEMBER MAY APPOINT ONE OR MORE INDIVIDUALS TO THE BOARD OF DIRECTORS, AND MAY AT ANY TIME REMOVE, WITH OR WITHOUT CAUSE, ANY MEMBER OF THE BOARD OF DIRECTORS. ACCORDING TO THE ORGANIZATION'S BYLAWS, DIRECTORS OF THE CORPORATION SHALL BE APPOINTED BY THE CORPORATE MEMBER NO LATER THAN JUNE 30 OF EACH YEAR. THE NAMES AND QUALIFICATIONS OF EACH INDIVIDUAL ACCEPTED BY THE BOARD OF DIRECTORS SHALL BE SUBMITTED TO THE CORPORATE MEMBER, WHO SHALL APPOINT OR REFUSE EACH NOMINEE IN ACCORDANCE WITH THE CORPORATE MEMBER'S BYLAWS AND WITH ENDORSEMENT OF THE SENIOR VICE PRESIDENT OF OPERATIONS. THE CORPORATE MEMBER MAY UNILATERALLY APPOINT ONE OR MORE INDIVIDUALS TO THE BOARD OF DIRECTORS SHOULD THE BOARD FAIL TO FURNISH THE CORPORATE MEMBER WITH A LIST OF INDIVIDUALS QUALIFIED TO SERVE ON THE BOARD OF DIRECTORS OF THE CORPORATION. (CHCF RESERVED RIGHTS) EXCEPT AS OTHERWISE PROVIDED IN THE CORPORATION'S ARTICLES OF INCORPORATION OR THE LAWS OF THE STATE OF ORGANIZATION, CATHOLIC HEALTH CARE FEDERATION ("CHCF") SHALL HAVE SUCH RIGHTS AS ARE RESERVED TO THE CORPORATE MEMBER, ACTING IN ITS CAPACITY AS THE MEMBERSHIP BODY OF CHCF, UNDER THE GOVERNANCE MATRIX. FORM 990, PART VI, SECTION A, LINE 7B THE ORGANIZATION'S CORPORATE MEMBER IS COMMONSPIRIT HEALTH. PURSUANT TO SECTION 5.4 OF THE ORGANIZATION'S BYLAWS, THE CORPORATE MEMBER SHALL HAVE THE SPECIFIC RIGHTS SET FORTH IN THE GOVERNANCE MATRIX. PURSUANT TO THE GOVERNANCE MATRIX THE FOLLOWING RIGHTS ARE RESERVED TO THE COMMONSPIRIT HEALTH BOARD DIRECTLY OR THROUGH POWERS DELEGATED TO THE COMMONSPIRIT HEALTH CHIEF EXECUTIVE OFFICER: -SUBSTANTIAL CHANGE IN THE MISSION OR PHILOSOPHY OF MERCY MEDICAL CENTER -AMENDMENT OF THE CORPORATE DOCUMENTS OF MERCY MEDICAL CENTER -APPROVE MEMBERS OF MERCY MEDICAL CENTER BOARD -REMOVAL OF A MEMBER OF THE GOVERNING BODY OF MERCY MEDICAL CENTER -APPROVAL OF ISSUANCE OF DEBT BY MERCY MEDICAL CENTER -APPROVAL OF PARTICIPATION OF MERCY MEDICAL CENTER IN A JOINT VENTURE -APPROVAL OF FORMATION OF A NEW CORPORATION BY MERCY MEDICAL CENTER -APPROVAL OF A MERGER INVOLVING MERCY MEDICAL CENTER -APPROVAL OF THE SALE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF MERCY MEDICAL CENTER -TO REQUIRE THE TRANSFER OF ASSETS BY MERCY MEDICAL CENTER TO COMMONSPIRIT HEALTH TO ACCOMPLISH COMMONSPIRIT HEALTH'S GOALS AND OBJECTIVES, AND TO SATISFY COMMONSPIRIT HEALTH DEBTS -ADOPTION OF LONG RANGE AND STRATEGIC PLANS FOR MERCY MEDICAL CENTER PURSUANT TO SECTION 5.5.2 OF THE ORGANIZATION'S BYLAWS, COMMONSPIRIT HEALTH MAY, IN EXERCISE OF ITS APPROVAL POWERS, GRANT OR WITHHOLD APPROVAL IN WHOLE OR IN PART, OR MAY, IN ITS COMPLETE DISCRETION, AFTER CONSULTATION WITH THE BOARD AND THE PRESIDENT AND CHIEF EXECUTIVE OFFICER OF THE ORGANIZATION, RECOMMEND SUCH OTHER OR DIFFERENT ACTIONS AS IT DEEMS APPROPRIATE. (CHCF RESERVED RIGHTS) EXCEPT AS OTHERWISE PROVIDED IN THE CORPORATION'S ARTICLES OF INCORPORATION OR THE LAWS OF THE STATE OF ORGANIZATION, CATHOLIC HEALTH CARE FEDERATION ("CHCF") SHALL HAVE SUCH RIGHTS AS ARE RESERVED TO THE CORPORATE MEMBER, ACTING IN ITS CAPACITY AS THE MEMBERSHIP BODY OF CHCF, UNDER THE GOVERNANCE MATRIX. FORM 990, PART VI, SECTION B, LINE 11B ONCE THE RETURN IS PREPARED, THE RETURN IS REVIEWED BY THE CHIEF FINANCIAL OFFICER. AN ELECTRONIC COPY OF THE RETURN IS SENT TO EACH BOARD MEMBER BY EMAIL FOR THEIR REVIEW. SUBSEQUENT TO RETURN BEING PROVIDED TO THE BOARD, THE TAX DEPARTMENT FILES THE RETURN WITH THE APPROPRIATE FEDERAL AND STATE AGENCIES, MAKING ANY NON-SUBSTANTIVE CHANGES NECESSARY TO EFFECT E-FILING. ANY SUCH CHANGES ARE NOT RE-SUBMITTED TO THE BOARD. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A CONFLICTS OF INTEREST ("COI") POLICY (THE "POLICY") IN PLACE TO PROTECT THE INTERESTS OF COMMONSPIRIT HEALTH ("COMMONSPIRIT") IN CIRCUMSTANCES THAT MAY RESULT IN A CONFLICT BETWEEN PERSONAL INTERESTS OF A PERSON AND THE INTERESTS OF THE ORGANIZATION AND THOSE IT SERVES. THE POLICY WAS LAST UPDATED DURING THE TAX YEAR ENDED 6/30/2021. COMMONSPIRIT'S COI POLICY APPLIES TO COMMONSPIRIT, ITS DIRECT AFFILIATES AND SUBSIDIARIES AND ANY RELATED ENTITY THE GOVERNING DOCUMENTS OF WHICH REQUIRE THE ENTITY TO COMPLY WITH COMMONSPIRIT POLICY (COLLECTIVELY THE "SYSTEM ENTITIES"). THE FOLLOWING PERSONS ARE REQUIRED TO DISCLOSE ACTUAL OR POTENTIAL CONFLICTS OF INTEREST AT LEAST ANNUALLY (VIA A FORMAL SYSTEM-ADMINISTERED SURVEY) IF THE PERSON'S AFFILIATION WITH COMMONSPIRIT CONTINUES: - MEMBERS OF CORPORATE AND COMMUNITY BOARDS OF SYSTEM ENTITIES - MEMBERS OF COMMITTEES OF CORPORATE AND COMMUNITY BOARDS OF SYSTEM ENTITIES - MEMBERS OF THE EXECUTIVE LEADERSHIP TEAM ("ELT") OF COMMONSPIRIT - CORPORATE OFFICERS OF SYSTEM ENTITIES - EMPLOYEES OF SYSTEM ENTITIES AT THE VICE PRESIDENT LEVEL AND ABOVE - ALL INDIVIDUALS ENGAGED IN RESEARCH AT INSTITUTIONS OWNED OR OPERATED BY A SYSTEM ENTITY. - SELECT EMPLOYEES AS DETERMINED FROM TIME TO TIME BY LEADERSHIP (WHICH INCLUDES KEY EMPLOYEES AND HIGHEST COMPENSATED EMPLOYEES AS SPECIFIED BY THE INTERNAL REVENUE SERVICE FOR FORM 990 PURPOSES WHO ARE NOT OTHERWISE INCLUDED IN THE CATEGORIES ABOVE). DISCLOSURE, REVIEW, AND MANAGEMENT OF PERCEIVED, POTENTIAL, OR ACTUAL CONFLICTS OF INTEREST ARE ACCOMPLISHED THROUGH A DEFINED COI DISCLOSURE REVIEW PROCESS. EACH PERSON IS REQUIRED TO PROMPTLY AND FULLY DISCLOSE ANY SITUATION OR CIRCUMSTANCE THAT MAY CREATE A CONFLICT OF INTEREST AS SOON AS SHE/HE BECOMES AWARE OF IT. IN ADDITION, AT THE INCEPTION OF AN INDIVIDUAL'S RELATIONSHIP WITH COMMONSPIRIT (E.G. HIRING, BOARD APPOINTMENT), AND FOR CERTAIN POSITIONS, ANNUALLY THEREAFTER, WRITTEN CONFLICT OF INTEREST DISCLOSURE FORMS MUST BE COMPLETED. A FAILURE TO DISCLOSE MAY RESULT IN DISCIPLINARY OR CORRECTIVE ACTIONS. REPORTED POTENTIAL OR ACTUAL CONFLICTS OF INTEREST ARE INITIALLY REVIEWED BY LEGAL, CORPORATE RESPONSIBILITY OR RESEARCH INTEGRITY STAFF. IF NECESSARY, A CONFLICT OF INTEREST MANAGEMENT PLAN IS DEVELOPED, WHICH PLAN SHALL BE SUBJECT TO ACCEPTANCE BY THE APPROPRIATE DIRECT MANAGER, SUPERVISOR, MEDICAL STAFF OFFICE, BOARD OR BOARD COMMITTEE (FOR BOARD, BOARD COMMITTEE, ELT OR CORPORATE OFFICER CONFLICTS), OR OTHER APPROPRIATE INDIVIDUAL OR BODY. ONCE ACCEPTED, THE CONFLICT OF INTEREST MANAGEMENT PLAN IS COMMUNICATED TO THE PERSON WITH THE ACTUAL OR POTENTIAL CONFLICT AND THE INDIVIDUAL MUST CONDUCT THEMSELVES IN CONFORMITY WITH THE PLAN. IN THE EVENT THAT A TRANSACTIONAL CONFLICT INTEREST ARISES IN CONNECTION WITH A SYSTEM ENTITY BOARD MEETING, THE CONFLICTED INDIVIDUAL MUST DISCLOSE THAT CONFLICT PRIOR TO OR AT THE BEGINNING OF THE MEETING IN WHICH THE MATTER IS TO BE CONSIDERED. THE CONFLICTED INDIVIDUAL IS EXCLUDED FROM VOTING ON THE TRANSACTION AND IS PROHIBITED FROM USING PERSONAL INFLUENCE WITH RESPECT TO THE MATTER, BUT IS NOT PROHIBITED FROM PROVIDING INPUT IF REQUESTED TO DO SO. FORM 990, PART VI, SECTION B, LINE 15A LINE 15A THE COMPENSATION OF THE PRESIDENT & CEO IS DETERMINED BY USING COMPENSATION SURVEY DATA AND REVIEWED WITH THE BOARD OF DIRECTORS AS NECESSARY. THE DELIBERATION AND DECISION ARE DOCUMENTED IN THE BOARD MINUTES AND THE PROCESS IS COMPLETED ANNUALLY. LINE 15B DURING THE TAX YEAR ENDED 6/30/2021, NO OFFICERS OR KEY EMPLOYEES RECEIVED COMPENSATION FROM THE ORGANIZATION. ANY EXECUTIVE COMPENSATION PAID TO OFFICERS, DIRECTORS OR TRUSTEES BY RELATED ORGANIZATIONS WAS SET BY THE RELATED ORGANIZATION'S COMPENSATION COMMITTEE UTILIZING BOTH AN INDEPENDENT CONSULTANT AND COMPARABILITY STUDIES TO DETERMINE COMPENSATION. THEREFORE, THESE QUESTIONS ARE MORE APPROPRIATELY ANSWERED AS N/A. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S FINANCIAL STATEMENTS, CONFLICT OF INTEREST POLICY AND GOVERNING DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. THE ORGANIZATION'S FINANCIAL STATEMENTS ARE INCLUDED IN COMMONSPIRIT HEALTH'S CONSOLIDATED AUDITED FINANCIAL STATEMENTS THAT ARE AVAILABLE AT WWW.COMMONSPIRIT.ORG. FORM 990, PART VI, LINE 14 THE DOCUMENT RETENTION AND DESTRUCTION POLICY IS MORE OF AN OPERATIONAL POLICY. THESE TYPES OF POLICIES USUALLY DO NOT GO TO THE BOARD OF DIRECTORS. THIS HAS NOT BEEN ADOPTED BY THE BOARD OF DIRECTORS. FORM 990, PART IX, LINE 11G OTHER FEES: PROGRAM SERVICE EXPENSES 20,571,131. MANAGEMENT AND GENERAL EXPENSES 1,371,182. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 21,942,313. FORM 990, PART XI, LINE 9: OTHER CHANGES -106,242. PRIOR PERIOD ADJUSTMENT CENTRALIZED TRANSACTIONS: TRANSFERS FOR JOURNAL ENTRIES RECORDED CENTRALLY AT COMMONSPIRIT TO STANDARDIZE CONTRACTUAL ALLOWANCE METHODOLOGY ACROSS ALL COMMONSPIRIT AFFILIATES AND SUBSIDIARIES. RECORDED CENTRALLY AT YEAR END AND TRANSFERRED TO FACILITIES IN THE FOLLOWING YEAR. ALEGENT CREIGHTON CLINIC 12809 W DODGE RD OMAHA NE 68154 470765154 HOSPITAL NE 501(C)(3) LINE 3 ACH 0 ALEGENT CREIGHTON HEALTH 12809 W DODGE RD OMAHA NE 68154 470757164 HOSPITAL NE 501(C)(3) LINE 3 CHI NEBRASKA 0 ALEGENT HEALTH - BERGAN MERCY HEALTH SYSTEM 7500 MERCY RD OMAHA NE 68124 470484764 HOSPITAL NE 501(C)(3) LINE 3 CHI NEBRASKA 0 ALEGENT HEALTH - COMMUNITY MEMORIAL HOSPITAL OF MISSOURI VALLEY IA 631 N 8TH ST MISSOURI VALLEY IA 51555 420776568 HOSPITAL IA 501(C)(3) LINE 3 CHI NEBRASKA 0 ALEGENT HEALTH - IMMANUEL MEDICAL CENTER 6901 N 72ND ST OMAHA NE 68122 470376615 HOSPITAL NE 501(C)(3) LINE 3 CHI NEBRASKA 0 ALEGENT HEALTH - MEMORIAL HOSPITAL SCHUYLER 104 W 17TH ST SCHUYLER NE 68661 470399853 HOSPITAL NE 501(C)(3) LINE 3 CHI NEBRASKA 0 ALEGENT HEALTH - MERCY HOSPITAL CORNING IOWA PO BOX 368 CORNING IA 50841 420782518 HOSPITAL IA 501(C)(3) LINE 3 CHI NEBRASKA 0 ALVERNA APARTMENTS 300 SE 8TH AVE LITTLE FALLS MN 56345 411351177 LTERM CARE MN 501(C)(3) LINE 10 CSH 0 APPLETREE COURT 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