2022-11-15T06:51:37-06:00 2021-12-31 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2021-01-01 390808498 THE RICHLAND HOSPITAL INC RICH 6086476321 333 EAST SECOND STREET RICHLAND CENTER WI 53581 ELIZABETH MOORE CHIEF FINANCIAL OFFICER 6086476321 2022-11-11 1 ELIZABETH MOORE 999009999 MICHAEL J PETERSON CPA P01833529 2187224705 2022-11-09 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z BRUCE ROESLER 333 EAST SECOND STREET RICHLAND CENTER WI 53581 78785128 0 X WWW.RICHLANDHOSPITAL.COM X 1937 WI THE RICHLAND HOSPITAL IS DEDICATED TO CARING, EDUCATING, AND HEALING. 10 8 512 118 991 0 4932664 5487617 56612144 65303983 739122 956218 274676 415537 62558606 72163355 35056 0 0 0 36103810 36229250 0 0 117305 23293993 25807841 59432859 62037091 3125747 10126264 84065288 90295177 13165800 8950106 70899488 81345071 THE RICHLAND HOSPITAL IS DEDICATED TO CARING, EDUCATING, AND HEALING - TO BE THE COMMUNITY'S FIRST CHOICE FOR BETTER HEATH. 0 0 47319845 0 47304830 THE RICHLAND HOSPITAL, INC. (THE HOSPITAL) OPERATES A 25-BED CRITICAL ACCESS HOSPITAL IN RICHLAND CENTER, WI. PATIENTS SERVED BY THE RICHLAND HOSPITAL IN 2021 INCLUDED 3,314 ADULTS AND PEDIATRICS INPATIENT DAYS, 383 SWING BED PATIENT DAYS, 215 NEWBORN PATIENT DAYS, 66,160 TOTAL OUTPATIENT VISITS, AND 6,474 EMERGENCY ROOM VISITS. THE HOSPITAL ALSO OPERATES A PHYSICIAN CLINIC PROVIDING PRIMARY CARE PROCEDURES SUCH AS CARDIAC TESTS AND ULTRASOUNDS. THE HOSPITAL ENGAGES IN SEVERAL EFFORTS THAT ARE DESCRIBED IN DETAIL ON THE SCHEDULE H ATTACHED TO THE RETURN. 3243819 0 17691403 THE RICHLAND HOSPITAL, INC. ALSO OPERATES TWO RURAL HEALTH CLINICS LOCATED IN SPRING GREEN AND MUSCODA, WI. DURING 2021 THESE TWO CLINICS PROVIDED OVER 7,396 VISITS TO PATIENTS IN BOTH COMMUNITIES. THE CLINICS ARE DESIGNATED RURAL HEALTH CLINICS BY THE MEDICARE AND MEDICAID PROGRAMS AND AS SUCH BY DEFINITION ARE LOCATED IN DESIGNATED RURAL OR UNDERSERVED AREAS OF THE COUNTRY BY HEALTH CARE PRACTITIONERS. THESE CLINICS PROVIDE CARE TO A LARGE PORTION OF MEDICARE AND MEDICAID BENEFICIARIES WHO WITHOUT ACCESS TO CARE LOCALLY WOULD BE REQUIRED TO TRAVEL FARTHER DISTANCES FOR QUALITY HEALTHCARE. 50563664 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 0 1 0 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 0 0 0 1 48 0 512 0 0 0 0 0 0 0 0 0 0 0 0 0 X 10 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 1 1 1 0 WI X ELIZABETH MOORE 6086476321 333 EAST SECOND STREET RICHLAND CENTER WI 53581 X CHRISTINE RICHARDS MD CHIEF OF STAFF 40.00 X 302995 0 28744 JOHN POOLE CHAIR 3.00 X X 0 0 0 MARILYN RINEHART VICE-CHAIR 2.00 X X 0 0 0 TRACI PETERSON SECRETARY 2.00 X X 0 0 0 JOHN ANNEAR TREASURER 2.00 X X 0 0 0 KAY BALINK MD DIRECTOR (& EMPLOYEE) 40.00 X 189001 0 40166 STEVE BAUER DIRECTOR 1.50 1.00 X 0 0 0 DOROTHY BEHLING DIRECTOR 1.50 X 0 0 0 JERRY GANDER DIRECTOR 1.50 X 0 0 0 JERRY MCCAULEY DIRECTOR 1.50 X 0 0 0 BRUCE ROESLER CEO 40.00 X 320750 0 41987 ELIZABETH MOORE CFO 40.00 1.00 X 77721 0 13704 JEFFERY LONGBRAKE INTERIM CFO (THRU AUG) 40.00 X 190590 0 0 THOMAS BECK ORTHOPEDIC SURGEON 40.00 X 574009 0 28915 BRYAN MCCARVEL CRNA 40.00 X 392230 0 10774 ANDREW WRIGHT FAMILY DOCTOR 40.00 X 374563 0 45042 ANDREW HARRIS ER MD DOCTOR 40.00 X 345736 0 51176 SHAWN O' BRIEN EMERGENCY PHYSICIAN 40.00 X 344689 0 46588 3112284 0 307096 9 0 1 0 RURAL PHYSICIANS GROUP 5575 DTC PKWY STE 225 GREENWOOD VILLAGE CO 80111 HOSPITALIST PROVIDER 843588 PSYCHIATRIC MEDICAL CARE LLC 4322 HARDING PIKE 417 NASHVILLE TN 37205 PSYCHIATRIC SERVICES 553221 MERITER KEALTH ENTERPRISES DBA MERITER L 36 SOUTH BROOKS STREET MADISON WI 53715 LABORATORY TESTING SERVICES 460565 MEDICAL SOLUTIONS LLC PO BOX 310737 DES MOINES IA 503310737 CONTRACTED LABOR-NURSING 226654 HURON CONSULTING SERVICES LLC 550 W VAN BUREN STREET CHICAGO IL 60607 MT EXPANSE SOFTWARE CONSULTING 217055 7 105810 5381807 5487617 PATIENT SERVICE REVENUE 621990 64086811 64085820 991 PHARMACY 340B REVENUE 446110 910413 910413 MEALS 722320 127895 127895 CONTRACTED THERAPY 621990 124861 124861 54003 54003 65303983 411534 411534 444700 29163 415537 415537 415537 7137294 6549909 42701 587385 -42701 544684 544684 72163355 64996233 991 1678514 X 964838 964838 28162824 23493995 4577555 91274 908683 694572 211164 2947 4348463 3278050 1056506 13907 1844442 1374741 463869 5832 126370 126370 42155 42155 7678967 6055915 1621813 1239 149374 573 148801 334811 179090 153920 1801 678607 678607 906579 902919 3660 37278 36066 1212 205342 122881 82156 305 3138380 2700809 437571 135833 60635 75198 SUPPLIES 7930280 7532187 398093 BAD DEBT EXPENSE 2931034 2931034 EQUIPMENT RENTAL & MAIN 954482 948209 6273 STATE HOSPITAL ASSESSME 281447 281447 276902 251988 24914 62037091 50563664 11356122 117305 1585 1488 24898639 29933448 11080824 11024020 2021007 2104042 233678 353883 70262678 44163632 25626258 26099046 17125183 18163195 639851 319926 2438263 2296129 84065288 90295177 7164200 6049745 65988 0 16611 0 5919001 2900361 13165800 8950106 X 70264315 81178059 635173 167012 70899488 81345071 84065288 90295177 X 10126264 145679 173640 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 6821 6821 0 PART II-B, LINE 1: THE RICHLAND HOSPITAL, INC. (THE "HOSPITAL") PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THESE DUES ARE PRIMARILY FOR ACCESS TO EDUCATIONAL MATERIALS AND STAFF TRAINING AND DEVELOPMENT. THE WHA HAD NOTIFIED THE HOSPITAL THAT APPROXIMATELY $2,483 OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. THE HOSPITAL IS ALSO A MEMBER OF THE RURAL WISCONSIN HEALTH COOPERATIVE (RWHC). EACH YEAR, THE HOSPITAL PAYS MEMBERSHIP FEES TO RWHC. THE RWHC PROVIDES SUPPORT SERVICES FOR A NUMBER OF ITS MEMBER HOSPITALS THROUGHOUT THE STATE OF WISCONSIN. SOME OF THE MANY SERVICES PROVIDED TO MEMBER HOSPITALS INCLUDE PROVIDING ASSISTANCE TO ORGANIZATIONS IN SECURING GRANT FUNDING FOR NEW OR EXISTING HEALTHCARE PROGRAMS, LEGAL SERVICES, REIMBURSEMENT REVIEW SERVICES, ACCOUNTING ASSISTANCE, CONTRACTING FOR THERAPIST COVERAGE, AND ADMINISTRATIVE CONSULTING SERVICES. AS A PART OF THESE SERVICES, RWHC ALSO DOES PROVIDE ANALYSIS OF CURRENT HEALTHCARE ISSUES IN AN EFFORT TO PROMOTE AND BETTER HEALTHCARE FOR HOSPITALS IN RURAL COMMUNITIES THROUGHOUT WISCONSIN. ONE OF THESE EFFORTS ALSO INCLUDES SOME LOBBYING ON BEHALF OF THE MEMBER ORGANIZATIONS. IT WAS DETERMINED THAT APPROXIMATELY $2,594 OF THE FEES PAID BY THE HOSPITAL IN 2021 RELATED TO LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE HEALTHCARE ENVIRONMENT IN THE STATE OF WISCONSIN. THE HOSPITAL IS ALSO A MEMBER OF THE AMERICAN HOSPITAL ASSOCIATION (AHA) IN WHICH $1,744 OF THEIR MEMBERSHIP DUES IS DEVOTED TO LOBBYING AND ADVOCATION AT A NATIONAL LEVEL. 76264 377 76641 75098 1166 76264 72416 2682 75098 71496 920 72416 71787 709 -1000 71496 0.00000 0.78000 0.22000 0 0 2153752 2153752 45438099 29245436 16192663 609073 609073 0 20526736 14309123 6217613 1535018 1535018 26099046 DEFERRED COMPENSATION PLAN LIABILITY 596091 OTHER DEFERRED GRANTS 1531046 AMOUNTS PAYABLE FROM THIRD-PARTY REIMBURSEMENT PROGRAMS 773224 2900361 69375108 145679 138925 284604 69090504 3072851 3072851 72163355 59099590 29163 29163 59070427 2966664 2966664 62037091 PART V, LINE 4: THE ENDOWMENT FUNDS MAINTAINED BY THE RICHLAND HOSPITAL, INC. HAVE BEEN RESTRICTED BY DONORS TO BE MAINTAINED IN PERPETUITY, THE INCOME OF WHICH IS EXPENDABLE TO SUPPORT SCHOLARSHIP PROGRAMS OF THE HOSPITAL. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES INCLUDED WITH EXPENSES ON FINANCIAL STATEMENTS 29,163. CHANGE IN NET ASSETS OF UNCONSOLIDATED AFFILIATES 109,762. PART XI, LINE 4B - OTHER ADJUSTMENTS: OTHER EXPENSES NET AGAINST REVENUE ON FINANCIAL STATEMENTS 35,630. PROVISION FOR BAD DEBTS NET AGAINST REVENUE ON FINANCIAL STATEMENTS 2,931,034. INVESTMENT INCOME RECORDED TO UNRESTRICTED NET ASSETS 377. CONTRIBUTIONS FROM FOUNDATION 105,810. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES INCLUDED WITH EXPENSES ON FINANCIAL STATEMENTS 29,163. PART XII, LINE 4B - OTHER ADJUSTMENTS: OTHER EXPENSES NET AGAINST REVENUE ON FINANCIAL STATEMENTS 35,630. PROVISION FOR BAD DEBTS NET AGAINST REVENUE ON FINANCIAL STATEMENTS 2,931,034. 1 1 X 1 X 1 X 1 1 1 0 1 1 216793 216793 0.00350 9324652 5170435 4154217 0.06700 9541445 5170435 4371010 0.07050 5033 5033 0.00010 4682914 3722975 959939 0.01550 752 752 0.00000 4688699 3722975 965724 0.01560 14230144 8893410 5336734 0.08610 1066933 1066933 0.01720 1066933 1066933 0.01720 0 1251950 625975 23044195 22830826 213369 X 1 1 1 1 THE RICHLAND HOSPITAL INC 333 EAST SECOND STREET RICHLAND CENTER WI 53581 WWW.RICHLANDHOSPITAL.COM 1045 X X X X THE RICHLAND HOSPITAL INC 1 0 0 1 X X X X X X X X X 19 1 0 1 1 X SEE PART V, SECTION C, LINE 7D X 1 16 1 SEE PART V, SECTION C, LINE 7D 0 1 X 150.000000000000 300.000000000000 X X X X 1 1 X X X 1 X SEE PART V, SECTION C X SEE PART V, SECTION C X SEE PART V, SECTION C X X X X X X 1 X 0 X X X X 1 X 0 0 THE RICHLAND HOSPITAL, INC. PART V, SECTION B, LINE 5: IN 2019, RICHLAND COUNTY PUBLIC HEALTH'S LOCAL HEALTH OFFICER, RICHLAND COUNTY UW EXTENSION FAMILY LIVING AGENT, AND THE RICHLAND HOSPITAL'S DIRECTOR OF MARKETING PARTNERED TO CONDUCT A COMBINED COMMUNITY HEALTH NEEDS ASSESSMENT AND IMPROVEMENT PLAN. AS A RESULT, A HEALTH ASSESSMENT AND WELLNESS COMMISSION (HAWC) MADE UP OF KEY STAKEHOLDERS IN THE COMMUNITY WAS ESTABLISHED TO CREATE AND OVERSEE THE PROCESS OF ASSESSING OUR COMMUNITY'S HEALTH AND WELLNESS NEEDS.MEMBERS OF THIS COMMISSION INCLUDED: 1. CHRIS DREA, RICHLAND HOSPITAL, DIRECTOR OF MARKETING2. MARCIA CARLSON, RICHLAND HOSPITAL, REGISTERED DIETITIAN AND CERTIFIED DIABETES EDUCATOR3. CHELSEA WUNNICKE, UW EXTENSION, RICHLAND COUNTY FAMILY LIVING AGENT4. ROSE KOHOUT, RICHLAND COUNTY HEALTH AND HUMAN SERVICES, PUBLIC HEALTH, COUNTY OFFICER5. CINDY CHICKER, RICHLAND HOSPITAL, ASSISTANT ADMINISTRATOR6. SHAWN TJOSSEM, RICHLAND SCHOOL DISTRICT, SCHOOL PSYCHOLOGIST7. JARRED BURKE, RICHLAND SCHOOL DISTRICT, DISTRICT ADMINISTRATOR8. BETSY ROESLER, RICHLAND COUNTY PUBLIC HEALTH, HEALTH AND WELLNESS COORDINATOR AND PREVENTION SPECIALIST9. MEGAN RYAN, RICHLAND HOSPITAL, ADMINISTRATIVE ASSISTANT DATA COLLECTION METHODOLOGY:AT EARLY MEETINGS OF THE HAWC'S IT WAS DETERMINED BY CONSENSUS TO COLLECT CHNA DATA IN 3 WAYS. THE COMMISSION ENVISIONED THIS AS A 3-LEGGED STOOL THAT WOULD SUPPORT OUR RECOMMENDATIONS OF THE TOP HEALTH NEEDS.1. SECONDARY DATA - PURPOSE: UNDERSTAND THE HEALTH ENVIRONMENT & DOCUMENTED REALITIES. HAWC MEMBERS CURATED PUBLISHED & PRIVATE HEALTH DATA.2. COMMUNITY SURVEY - PURPOSE: COLLECT OPINIONS THAT CAN STATISTICALLY REPRESENT RICHLAND COUNTY. MAILED TO 2,000 RANDOMLY GENERATED RESIDENCE ADDRESSES IN RICHLAND COUNTY.3. STAKEHOLDER FOCUS GROUPS - PURPOSE: MULTI-SECTOR STAKEHOLDERS REVIEW THE RESULTS OF THE COMMUNITY SURVEY AND PRIORITIZE NEEDS. FOCUS GROUPS WERE BY INVITATION ONLY. THE RICHLAND HOSPITAL, INC. PART V, SECTION B, LINE 6B: RICHLAND COUNTY HEALTH AND HUMAN SERVICES THE RICHLAND HOSPITAL, INC. PART V, SECTION B, LINE 7D: SCHEDULE H, PART V, LINE 7AHTTPS://WWW.RICHLANDHOSPITAL.COM/ABOUT-US/COMMUNITY-HEALTH-ASSESSMENT/SCHEDULE H, PART V, LINE 10AHTTPS://WWW.RICHLANDHOSPITAL.COM/ABOUT-US/COMMUNITY-HEALTH-ASSESSMENT/ THE RICHLAND HOSPITAL, INC. PART V, SECTION B, LINE 11: IN PLANNING TO MEET COMMUNITY NEEDS, THE HOSPITAL WORKS CLOSELY WITH KEY COMMUNITY STAKEHOLDERS TO ASSESS HOW COMMUNITY HEALTH NEED PRIORITIES IDENTIFIED IN THE 2020 COMMUNITY HEALTH NEEDS ASSESSMENT ARE BEING ADDRESSED. THE RICHLAND HOSPITAL CREATED AND ADOPTED A COMMUNITY HEALTH IMPROVEMENT PLAN (CHIP) THAT SERVES AS A ROAD MAP FOR THE ORGANIZATION TO MAINTAIN A KEEN EYE ON THOSE PRIORITIES. THE HOSPITAL'S COMMUNITY CONNECTIONS TEAM OVERSEES THE CHIP. INDIVIDUAL MEMBERS SERVE AS PRIORITY CHAMPIONS AND WORK WITH GOAL CHAMPIONS TO ENSURE THAT THE HOSPITAL CONTINUES TO PURSUE IMPROVEMENT IN THESE AREAS. THE THREE PRIORITIES IDENTIFIED IN THE COMMUNITY INCLUDED: 1. MENTAL HEALTH 2. SUBSTANCE ABUSE TREATMENT AND PREVENTION 3. OBESITY TREATMENT AND PREVENTIONIN 2021, COVID-19 AND OUR PRECAUTIONS AROUND THE PANDEMIC CHALLENGED US TO FIND NEW WAYS TO MAKE PROGRESS AROUND ADDRESSING OUR COMMUNITY HEALTH NEEDS; IN-PERSON EVENTS WERE NOT AN OPTION, MANY EVENTS SPONSORED WITHIN THE COMMUNITY CONTINUED TO BE CANCELLED. OUR COMMUNITY CONNECTIONS COMMITTEE IN COOPERATION WITH OUR WELLNESS COMMITTEE FOUND CREATIVE WAYS TO ADDRESS THE THREE TOP COMMUNITY HEALTH NEEDS BY HOSTING VIRTUAL EVENTS SUCH AS A VIRTUAL 5K AND WELLNESS STRATEGIES VIA SOCIAL MEDIA PLATFORMS. DESPITE THESE EFFORTS TO ADDRESS OUR AUDIENCES AND ISSUES IDENTIFIED IN OUR CHIP VIRTUALLY, COVID-19 WAS OUR PREDOMINANT FOCUS FOR 2021 THE RICHLAND HOSPITAL, INC. PART V, SECTION B, LINE 13H: IN ADDITION TO THE FEDERAL POVERTY GUIDELINES, THE RICHLAND HOSPITAL, INC. CONSIDERS THE FOLLOWING WHEN DETERMINING ELIGIBILITY FOR PROVIDING "FREE OR "DISCOUNTED" CARE TO INDIVIDUALS:- PATIENT IS HOMELESS- PATIENT IS ELIGIBLE FOR OTHER STATE OR LOCAL ASSISTANCE PROGRAMS THAT ARE UNFUNDED- PATIENT IS ELIGIBLE FOR ASSISTANCE UNDER THE CRIME VICTIMS ACT OR SEXUAL ASSAULT ACT- PATIENT IS DECEASED, AND WITHOUT A SPOUSE, AND NO ESTATE HAS BEEN FILED WITH THE COURT SYSTEM WITHIN 12 MONTHS OF EXPIRATION OR IF IT DETERMINED PATIENT DOES NOT HAVE ASSETS REQUIRING THE FILING OF AN ESTATE- PATIENT RECEIVES A BANKRUPTCY DETERMINATION WITHIN THE SIX MONTHS IMMEDIATELY PRECEDING THE APPLICATION DATE IF APPLICANT IS LOOKING FOR CONSIDERATION ON ANY ACTIVE ACCOUNT NOT DISCHARGED AS A PART OF THE BANKRUPTCY DETERMINATION- PATIENT'S VALID ADDRESS IS CONSIDERED LOW INCOME OR SUBSIDIZED HOUSING AND PATIENT AUTHORIZES THE APPLICABLE HOUSING AUTHORITY TO VALIDATE INCOME LEVEL DIRECTLY TO THE HOSPITAL- ACCOUNTS RETURNED BY COLLECTION AGENCY- ACCOUNTS CLOSED AS A RESULT OF A COURT-ORDER-PATIENT IS ELIGIBLE FOR FOOD STAMPS OR SUBSIDIZED SCHOOL LUNCH PROGRAM THE RICHLAND HOSPITAL, INC. PART V, SECTION B, LINE 16J: PLAIN LANGUAGE SUMMARY IS INCLUDED IN WRITTEN ACCOUNT COMMUNICATION, PLAIN LANGUAGE SUMMARY IS OFFERED AT REGISTRATION, PLAIN LANGUAGE SUMMARY IS INCLUDED ON STATEMENTS. PART V, SECTION C, LINES 16A-C: HTTPS://WWW.RICHLANDHOSPITAL.COM/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE- 2 1 - MUSCODA HEALTH CENTER 1075 NORTH WISCONSIN AVENUE MUSCODA WI 53573 RURAL HEALTH CLINIC 2 - SPRING GREEN MEDICAL CENTER 150 EAST JEFFERSON STREET SPRING GREEN WI 53588 RURAL HEALTH CLINIC PART I, LINE 3C: ADDITIONALLY, THE RICHLAND HOSPITAL, INC. MAY REFER TO OR RELY ON EXTERNAL SOURCES AND/OR OTHER PROGRAM ENROLLMENT RESOURCES IN THE CASE OF PATIENTS LACKING DOCUMENTATION THAT SUPPORTS ELIGIBILITY OR INDIVIDUAL CIRCUMSTANCE. AT ITS SOLE DISCRETION, WHEN A PATIENT IS UNABLE TO PROVIDE NECESSARY DOCUMENTATION TO SUPPORT AN ELIGIBILITY DETERMINATION, THE RICHLAND HOSPITAL, INC. MAY PROVIDE FREE OR DISCOUNTED SERVICES UNDER THIS PROGRAM WHEN PATIENT: - IS HOMELESS - IS ELIGIBLE FOR OTHER STATE OR LOCAL ASSISTANCE PROGRAMS THAT ARE UNFUNDED - IS ELIGIBLE FOR FOOD STAMPS OR SUBSIDIZED SCHOOL LUNCH PROGRAM - IS ELIGIBLE FOR ASSISTANCE UNDER THE CRIME VICTIMS ACT OR SEXUAL ASSAULT ACT - IS DECEASED, WITHOUT A SPOUSE, AND NO ESTATE HAS BEEN FILED WITH THE COURT SYSTEM WITHIN 12 MONTHS OF EXPIRATION OR AT THE TIME IT CAN BE DETERMINED PATIENT DOES NOT HAVE ASSETS REQUIRING THE FILING OF AN ESTATE. - RECEIVES A BANKRUPTCY DETERMINATION WITHIN THE SIX MONTHS IMMEDIATELY PRECEDING THE APPLICATION DATE IF APPLICANT IS LOOKING FOR CONSIDERATION ON ANY ACTIVE ACCOUNT NOT DISCHARGED AS A PART OF THE BANKRUPTCY DETERMINATION. - VALID ADDRESS IS CONSIDERED LOW INCOME OR SUBSIDIZED HOUSING AND PATIENT AUTHORIZES THE APPLICABLE HOUSING AUTHORITY TO VALIDATE INCOME LEVEL DIRECTLY TO THE HOSPITAL. PART I, LINE 6A: THE RICHLAND HOSPITAL, INC. PREPARES A COMMUNITY BENEFIT REPORT ANNUALLY AND FILES IT WITH THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THE REPORT IS AVAILABLE TO THE GENERAL PUBLIC ON WHA'S DATABASE AND WEBSITE. PART I, LINE 7: THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST-TO-CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST-TO-CHARGE RATIO IS APPLIED AGAINST VARIOUS REVENUE AND EXPENSE CATEGORIES TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER IRS SUGGESTED COSTING METHODS FOR THE FORM 990. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES AT THE RICHLAND HOSPITAL, INC. INCLUDES THE OPERATION OF THE HOSPITAL EMERGENCY ROOM DEPARTMENT AND THE INTENSIVE CARE INPATIENT UNIT. THESE SERVICES ARE UNAVAILABLE TO MEMBERS OF THE COMMUNITY OTHER THAN THROUGH THE RICHLAND HOSPITAL, INC. AND ARE PRIMARILY UTILIZED FOR EMERGENCY SERVICES. THE EMERGENCY ROOM DEPARTMENT OPERATES 24-HOURS PER DAY, SEVEN DAYS PER WEEK AND IS STAFFED PRIMARILY BY BOARD CERTIFIED EMERGENCY ROOM PHYSICIANS. AS PART OF THE PATIENT SERVICES PROVIDED TO THE COMMUNITY, THE HOSPITAL HAS DESIGNATED A PORTION OF ITS INPATIENT UNIT AS A CERTIFIED INTENSIVE CARE UNIT KNOWN AS THE "SPECIAL CARE UNIT." THIS UNIT REQUIRES A HIGHER ACUITY OF NURSING AND HAS DEDICATED STAFF TO PROVIDE THIS CARE TO PATIENTS. A SIGNIFICANT PORTION OF THE ADMISSIONS TO THE UNIT COME FROM EMERGENCY ADMISSIONS TO THE HOSPITAL SO IT IS CONSIDERED A SUBSIDIZED HEALTH SERVICE PROVIDED TO THE COMMUNITY BY THE HOSPITAL. IT IS THE GOAL OF THE RICHLAND HOSPITAL, INC. TO PROVIDE THESE SERVICES TO THE COMMUNITY REGARDLESS OF THE PATIENT'S ABILITY TO PAY. PART II, COMMUNITY BUILDING ACTIVITIES: THE RICHLAND HOSPITAL, INC. IS ACCREDITED THROUGH THE JOINT COMMISSION ("TJC"). THE TJC IS AN ORGANIZATION THAT EVALUATES HOSPITAL PERFORMANCE STANDARDS, FOCUSING ON THE QUALITY OF HEALTHCARE. ACCREDITATION THROUGH THE JOINT COMMISSION IS RECOGNIZED NATIONWIDE AS A SYMBOL OF QUALITY, AS IT REQUIRES RIGOROUS PERFORMANCE STANDARDS. TO EARN AND MAINTAIN ACCREDITATION, THE HOSPITAL IS EVALUATED THROUGH AN UNANNOUNCED SURVEY PROCESS COVERING NEARLY 600 STANDARDS RELATED TO QUALITY PATIENT CARE, SAFETY, INFECTION CONTROL, AND ONGOING PERFORMANCE-IMPROVEMENT ACTIVITIES, AMONG OTHERS. ALL HOSPITALS SURVEYED BY THE JOINT COMMISSION ARE EVALUATED AGAINST THE SAME CRITERIA, REGARDLESS OF SIZE OR LOCATION.THE ACTIVITIES OF THE RICHLAND HOSPITAL, INC. ARE SUPPORTED LOCALLY BY A VOLUNTEER BOARD OF DIRECTORS WHICH OVERSEE THE OPERATIONS OF THE HOSPITAL. THE BOARD OF DIRECTORS IS MADE UP OF COMMUNITY MEMBERS THAT RESIDE IN RICHLAND CENTER, WI, AND THE SURROUNDING AREA WHICH IS THE HOSPITAL'S PRIMARY PATIENT SERVICE AREA. THE HOSPITAL ALSO EXTENDS MEDICAL STAFF PRIVILEGES TO A MAJORITY OF ALL QUALIFIED PHYSICIANS IN THE COMMUNITY AND SURROUNDING AREAS WHO WISH TO BETTER SERVE THEIR PATIENTS BY PROVIDING CARE AT THE RICHLAND HOSPITAL, INC.ANY SURPLUSES IN OPERATIONS THAT ARE ACHIEVED BY THE HOSPITAL OPERATING IN AN EFFECTIVE MANNER AND CONTROLLING THE COST OF HEALTHCARE ARE PRIMARILY RESERVED FOR FUTURE BUILDING AND CAPITAL PURCHASE NEEDS. THE RICHLAND HOSPITAL, INC. RECOGNIZES THAT IT IS IMPORTANT TO SAVE THESE RESERVES DURING YEARS OF SURPLUS SO THAT IN TIMES OF ECONOMIC DOWNTURN, IF A LARGE CAPITAL ADDITION IS NEEDED, THE HOSPITAL WILL NOT HAVE TO PASS HIGHER COSTS ON TO MEMBERS OF THE COMMUNITY. THE HOSPITAL FURTHER ACHIEVES ITS GOAL OF PROVIDING TRUE COMMUNITY SUPPORT BY PROVIDING CHARITY CARE AS DESCRIBED THROUGHOUT SCHEDULE H AND PROVIDING SERVICES TO MEMBERS OF OTHER PROGRAMS WHICH OFTEN REIMBURSE THE HOSPITAL BELOW THE COST OF PROVIDING THIS CARE SUCH AS CHAMPUS, TRICARE, AND THE WISCONSIN HEALTH INSURANCE RISK SHARING PROGRAM OR "HIRSP" (THE HIRSP PROGRAM REIMBURSES THE HOSPITAL AT RATES SIMILAR TO THE MEDICAID PROGRAM AND IS FOR PATIENTS THAT HAVE PRE-EXISTING ILLNESSES WHICH MAKE IT DIFFICULT TO OBTAIN INSURANCE FROM COMMERCIAL INSURANCE CARRIERS IN THE MARKETPLACE). PART III, LINE 2: THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST-TO-CHARGE RATIO, WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES, EXCLUDING THE PROVISION FOR BAD DEBT, DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST-TO-CHARGE RATIO IS APPLIED AGAINST THE TOTAL CHARGES THAT ARE WRITTEN OFF DURING THE YEAR TO ESTIMATE THE COST OF CARE OF PATIENTS WHO HAVE ACCOUNTS THAT ARE DEEMED TO BE BAD DEBTS TO THE HOSPITAL. THE HOSPITAL ALSO RECOGNIZES THAT IT ALSO PROVIDES A DISCOUNT TO SELF-PAY OR UNINSURED PATIENTS. THESE AMOUNTS ARE EXCLUDED FROM GROSS PATIENT SERVICE REVENUE ON THE CONSOLIDATED FINANCIAL STATEMENTS AND ARE NOT INCLUDED IN THE RATIO AS DESCRIBED ABOVE AND APPROVED BY THE IRS FOR USE ON FORM 990. IF CONSIDERED, THESE ADDITIONAL WRITE-OFF AMOUNTS TO UNINSURED ACCOUNTS WOULD ALSO INCREASE THE ESTIMATED BAD DEBT EXPENSE AMOUNT ASSOCIATED WITH THESE UNCOLLECTIBLE ACCOUNTS TO THE HOSPITAL. PART III, LINE 3: MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER THE HOSPITAL HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND CREDIT TO ACCOUNTS RECEIVABLE. MANY TIMES, PATIENTS DO NOT COMPLETE THE REQUIRED CHARITY CARE APPLICATION AND ARE TRANSFERRED TO COLLECTION SERVICES EVEN THOUGH THE HOSPITAL PROVIDES THIS INFORMATION TO ALL PATIENTS AND ASSISTS PATIENTS WITH THE APPLICATION. DUE TO NO RESPONSES FROM SOME PATIENTS, A SIGNIFICANT AMOUNT OF BAD DEBTS COULD BE CONSIDERED AS CHARITY CARE. PART III, LINE 4: IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES PAST RESULTS AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. SPECIFICALLY, FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS AND PATIENTS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES, IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. THE AUDITED FINANCIAL STATEMENTS DO NOT CONTAIN A SEPARATE FOOTNOTE REGARDING BAD DEBT EXPENSE. PART III, LINE 8: THE RICHLAND HOSPITAL, INC. IS DESIGNATED AS A CRITICAL ACCESS HOSPITAL AND, AS SUCH, A PORTION OF ITS REVENUE IS PAID UNDER A COST REIMBURSEMENT SYSTEM. THE TOTAL MEDICARE REVENUE SHOWN BASED ON THE IRS 990 INSTRUCTIONS INCLUDES ONLY A PORTION OF THE TOTAL MEDICARE REVENUE OF THE HOSPITAL. THE AMOUNTS LISTED FOR MEDICARE DO NOT INCLUDE PHYSICIAN SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT, RADIOLOGIST SERVICES, AND SURGICAL ANESTHESIA SERVICES AT THE RICHLAND HOSPITAL, INC. PHYSICIAN COVERAGE IS REIMBURSED PRIMARILY ON FEE SCHEDULE REIMBURSEMENT AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY SERVICES PROVIDED TO MEDICARE PATIENTS ARE VITAL TO THE WELL-BEING OF THE COMMUNITY AND, AS SUCH, THESE COSTS AND SHORTFALLS SHOULD ALSO BE CONSIDERED AS AN ADDITIONAL BENEFIT THAT THE RICHLAND HOSPITAL, INC. PROVIDES TO THE COMMUNITIES IT SERVES. THE COSTING METHOD USED ABOVE FOR IRS FORM 990 COMPLIANCE REPORTING IS ALSO BASED ON AN OVERALL AVERAGE COST-TO-CHARGE RATIO AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUE (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE) DIVIDED BY TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT EXPENSE. THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES WHICH ARE REIMBURSED ON A COST METHODOLOGY EXCLUDING THE FEE SCHEDULE ITEMS LIKE PHYSICIAN SERVICES AND THE HOSPITAL WOULD SHOW A LARGE LOSS ON THESE SERVICES.WHETHER THERE IS A SHORTFALL OR SURPLUS FROM SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PEOPLE, WHO ARE TYPICALLY ELDERLY MEMBERS OF THE COMMUNITY, ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. PART III, LINE 9B: AT THE TIME OF PATIENT PRESENTATION, THE RICHLAND HOSPITAL, INC. WILL GATHER DEMOGRAPHIC AND INSURANCE INFORMATION THAT SUPPORTS THE TIMELY GENERATION AND RELEASE OF INSURANCE CLAIM FORMS AND /OR SELF-PAY STATEMENTS FOR SERVICES RENDERED. SUBJECT TO COMPLIANCE WITH THE PROVISIONS OF THIS POLICY, THE RICHLAND HOSPITAL, INC. MAY TAKE ANY AND ALL LEGAL ACTIONS, INCLUDING EXTRAORDINARY COLLECTION ACTIONS (ECA'S), TO OBTAIN PAYMENT FOR MEDICAL SERVICES PROVIDED. THE RICHLAND HOSPITAL, INC. WILL NOT ENGAGE IN ECA'S, EITHER DIRECTLY OR BY ANY DEBT COLLECTIONS AGENCY OR OTHER PARTY TO WHICH THE HOSPITAL HAS REFERRED THE PATIENT'S DEBT, BEFORE REASONABLE EFFORTS ARE MADE TO DETERMINE WHETHER A RESPONSIBLE INDIVIDUAL^) IS ELIGIBLE FOR ASSISTANCE UNDER THE COMMUNITY CARE PROGRAM, FINANCIAL ASSISTANCE POLICY. AT THE POINT A RESPONSIBLE INDIVIDUAL REQUESTS A COMMUNITY CARE PROGRAM APPLICATION, THE ABOVE PROCEDURE WILL CEASE, AND THE FOLLOWING PROCEDURE WILL TAKE EFFECT.UPON REQUEST, A COMMUNITY CARE PROGRAM APPLICATION WILL BE SENT/GIVEN TO THE RESPONSIBLE INDIVIDUAL ALONG WITH A COVER LETTER DETAILING DOCUMENTATION REQUIRED TO PROCESS THE APPLICATION.APPLICATION MUST BE RETURNED WITHIN 30 DAYS FROM THE DATE THE RESPONSIBLE INDIVIDUAL IS GIVEN OR MAILED THE APPLICATION.IF INCOMPLETE OR INSUFFICIENT DOCUMENTATION IS RECEIVED, RESPONSIBLE INDIVIDUAL WILL BE NOTIFIED IN WRITING OF THE MISSING OR INCOMPLETE DOCUMENTATION. RESPONSIBLE INDIVIDUAL WILL HAVE 30 DAYS FROM THE DATE OF THE NOTIFICATION TO PROVIDE THE MISSING INFORMATION OR DOCUMENTATION. FAILURE TO SUBMIT A COMPLETED APPLICATION OR SUBSEQUENTLY REQUESTED DOCUMENTATION WITHIN 30 DAYS MAY RESULT IN THE APPLICATION BEING DENIED, THE ACCOUNT BEING REFERRED TO AN EXTERNAL COLLECTION AGENCY AND ECA'S MAY COMMENCE. IF A COMMUNITY CARE PROGRAM APPLICATION IS RECEIVED AFTER AN ACCOUNT HAS BEEN REFERRED TO AN EXTERNAL COLLECTION AGENCY, BUT PRIOR TO 240 DAYS FROM THE DATE OF THE FIRST POST-DISCHARGE BILLING STATEMENT, THE EXTERNAL COLLECTION AGENCY WILL BE INSTRUCTED TO DISCONTINUE COLLECTION ACTIVITY UNTIL THE COMMUNITY CARE PROGRAM APPLICATION HAS BEEN PROCESSED. IF THE APPLICATION IS APPROVED FOR A FULL OR PARTIAL DISCOUNT, THE EXTERNAL COLLECTION AGENCY WILL BE NOTIFIED AND INSTRUCTED TO REMOVE OR REVERSE ANY ECAS THAT MAY HAVE BEEN TAKEN AND THE ACCOUNT WILL BE REFERRED BACK TO THE RICHLAND HOSPITAL, INC.RESPONSIBLE INDIVIDUALS APPROVED FOR A PARTIAL DISCOUNT WILL BE NOTIFIED IN WRITING OF THEIR APPROVAL FOR A PARTIAL DISCOUNT AND AN UPDATED STATEMENT REFLECTING THE NEW DISCOUNTED AMOUNT DUE WILL BE INCLUDED. RESPONSIBLE INDIVIDUALS DETERMINED TO BE INELIGIBLE FOR A COMMUNITY CARE PROGRAM DISCOUNT WILL BE NOTIFIED IN WRITING OF THEIR INELIGIBILITY. THE NOTIFICATION TO RESPONSIBLE INDIVIDUALS DETERMINED TO BE INELIGIBLE FOR A COMMUNITY CARE PROGRAM DISCOUNT OR ELIGIBLE FOR A PARTIAL DISCOUNT WILL INCLUDE A PAYMENT PLAN AGREEMENT. RESPONSIBLE INDIVIDUAL WILL BE PROVIDED 30 DAYS TO COMPLETE AND RETURN THE PAYMENT PLAN AGREEMENT. FAILURE TO RETURN A COMPLETED PAYMENT PLAN AGREEMENT WITHIN 30 DAYS COULD RESULT IN THE ACCOUNT BEING REFERRED TO AN EXTERNAL COLLECTION AGENCY AND ECAS MAY COMMENCE. HOSPITAL AND EXTERNAL COLLECTION AGENCIES MAY ALSO TAKE ANY AND ALL LEGAL ACTIONS INCLUDING BUT NOT LIMITED TO TELEPHONE CALLS, EMAILS, TEXTS, MAILING NOTICES AND SKIP TRACING TO OBTAIN PAYMENT FOR MEDICAL SERVICES PROVIDED PART VI, LINE 2: IN ADDITION TO THE COMPREHENSIVE COMMUNITY HEALTH NEEDS ASSESSMENT CONDUCTED IN 2019, THE RICHLAND HOSPITAL, INC. ASSESSES THE HEALTHCARE NEEDS OF THE COMMUNITY IT SERVES BY LOOKING AT LOCAL AND SURROUNDING COMMUNITY DEMOGRAPHICS TO DETERMINE THE SERVICES THAT ARE MOST NECESSARY IN ORDER TO FULFILL ITS MISSION. THE HOSPITAL ACTIVELY SEEKS INPUT FROM MEMBERS OF THE MEDICAL STAFF REGARDING EXISTING SERVICES, POTENTIAL NEED FOR EXPANDED SERVICES, AND THE POTENTIAL NEED FOR NEW SERVICE LINES NOT OFFERED LOCALLY. THE HOSPITAL MONITORS THE LOSS OF SPECIALTY PROVIDERS IN THE AREA AND, COLLABORATIVELY WORKING WITH OUR RURAL HEALTH CLINICS (RICHLAND HOSPITAL CLINIC, SPRING GREEN MEDICAL CENTER, AND MUSCODA HEALTH CENTER), PARTICIPATES IN A DETERMINATION OF WHETHER AND HOW THIS NEW NEED CAN BEST BE MET. A RECENT EXAMPLE WAS THE IMPENDING LOSS OF A GENERAL SURGEON DUE TO RETIREMENT. THE HOSPITAL ALSO REVIEWS HOSPITAL STATISTICS OF PATIENT VISITS TO DETERMINE WHAT TYPES OF SERVICES OFFERED BY THE HOSPITAL ARE BEING UTILIZED. PART VI, LINE 3: CONSISTENT WITH THE MISSION OF THE RICHLAND HOSPITAL, INC., HEALTH-RELATED SERVICES ARE PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. THE HOSPITAL IS COMMITTED TO PROVIDING FREE OR DISCOUNTED CARE TO QUALIFIED INDIVIDUALS THAT ARE IN NEED OF MEDICALLY NECESSARY TREATMENT EVEN IF THAT PERSON IS UNINSURED, UNDERINSURED, INELIGIBLE FOR OTHER GOVERNMENT PROGRAMS, OR UNABLE TO PAY BASED ON THEIR INDIVIDUAL FINANCIAL SITUATION. WHEN AN UNINSURED OR UNDERINSURED PATIENT REQUESTS FINANCIAL ASSISTANCE AND HAS AN ADJUSTED GROSS INCOME THAT IS AT OR BELOW 150% OF THE FEDERAL POVERTY LEVEL, THEY ARE ELIGIBLE FOR A 100% DISCOUNT ON ANY PATIENT BALANCE. WHEN AN UNINSURED PATIENT'S ADJUSTED GROSS INCOME IS 151 TO 300% OF THE FEDERAL POVERTY LEVEL, THEY ARE PROVIDED CARE AT THE AMOUNT GENERALLY BILLED OR LESS. FOR UNDERINSURED PATIENTS WITH AN ADJUSTED GROSS INCOME OF 151 TO 300%, THE AMOUNT PATIENT IS CHARGED AND RESPONSIBLE FOR PAYING (CO-INSURANCE, DEDUCTIBLES, ETC.) AFTER APPLYING DEDUCTIONS, DISCOUNTS AND PAYMENTS APPLIED BY THE THIRD PARTY PAYER WILL NOT BE GREATER THAN THE AGB. TO BE ELIGIBLE UNDER THIS PROGRAM, PATIENTS MUST COOPERATE WITH THE HOSPITAL TO EXPLORE ALTERNATIVE MEANS OF ASSISTANCE AND IF NECESSARY, INCLUDING APPLICATION OR ACTIONS NEEDED TO SECURE COVERAGE BY MEDICARE, MEDICAID, AND THE MARKETPLACE. PATIENTS WILL BE REQUIRED TO PROVIDE NECESSARY INFORMATION AND DOCUMENTATION WHEN APPLYING FOR A PROGRAM DISCOUNT, OR FOR OTHER PRIVATE OR PUBLIC PAYMENT PROGRAMS. THE FACILITY'S FINANCIAL COUNSELOR IS AVAILABLE TO ASSIST PATIENTS WITH THE APPLICATION PROCESS. APPLICATIONS AND ALL SUPPORTING DOCUMENTATION IS REVIEWED BY THE FACILITY'S FINANCIAL COUNSELOR FOR ELIGIBILITY AND APPROVED BY THE PATIENT ACCOUNTING SUPERVISOR. FREE RADIOLOGY, LABORATORY, AND OTHER DIAGNOSTIC ANCILLARY SERVICES ARE ALSO PROVIDED TO PATIENTS WHO ARE REFERRED TO THE HOSPITAL BY THE RICHLAND CENTER FREE CLINIC. THE HOSPITAL ALSO OFFERS A 20% PROMPT PAY DISCOUNT FOR UNINSURED PATIENTS.THE RICHLAND HOSPITAL, INC. COMMUNICATES THE AVAILABILITY AND TERMS OF THE PROGRAM TO ALL PATIENTS, THROUGH MEANS WHICH INCLUDE, BUT ARE NOT LIMITED TO:1. POSTED SIGNS WITHIN WAITING ROOMS, EMERGENCY ROOMS, AND PATIENT ACCOUNTING AREAS.2. COMMUNITY CARE PROGRAM APPLICATION AND PLAIN LANGUAGE SUMMARY OFFERED TO INDIVIDUALS AT TIME OF REGISTRATION AND DISCHARGE FROM AN INPATIENT ADMISSION. THE COMMUNITY CARE PROGRAM POLICY, COMMUNITY CARE PROGRAM APPLICATION AND THE PLACEMENT FOR COLLECTION POLICY ARE AVAILABLE UPON REQUEST. SPANISH VERSIONS WILL ALSO BE AVAILABLE UPON REQUEST.3. PLAIN LANGUAGE SUMMARY, COMMUNITY CARE PROGRAM POLICY, COMMUNITY CARE PROGRAM APPLICATION AND PLACEMENT FOR COLLECTIONS POLICY INCLUDING SPANISH VERSIONS CAN BE OBTAINED BY:A. REQUESTING IN PERSON AT THE RICHLAND HOSPITAL, INC., RICHLAND HOSPITAL CLINIC, SPRING GREEN MEDICAL CENTER AND MUSCODA HEALTH CENTERB. CONTACTING THE RICHLAND HOSPITAL, INC. PATIENT ACCOUNTING DEPARTMENT AT 608-647-6321.C. ACCESSING THE RICHLAND HOSPITAL, INC. WEBSITE D. SUBMITTING A WRITTEN REQUEST TO THE RICHLAND HOSPITAL, INC.4. PLAIN LANGUAGE SUMMARY PROVIDED WITH WRITTEN CORRESPONDENCE.5. CONSPICUOUS MESSAGE ON PATIENT STATEMENTS.6. PLAIN LANGUAGE SUMMARY AVAILABLE AT THE LOCAL AGING AND DISABILITY RESOURCE CENTER AND AT THE RICHLAND COMMUNITY FREE CLINIC.7. DESIGNATED STAFF KNOWLEDGEABLE ON THE PROGRAM WILL BE AVAILABLE TO ANSWER PATIENT QUESTIONS AND/OR REFER PATIENTS TO THE PROGRAM.REGISTRATION CLERKS AT THE HOSPITAL, THE HOSPITAL CLINIC AND AT THE TWO HOSPITAL OWNED CLINICS, ARE TRAINED TO INQUIRE WITH PATIENTS UPON REGISTRATION IF THEY WOULD LIKE INFORMATION ON THIS PROGRAM. DURING THE COLLECTION PROCESS, THE RICHLAND HOSPITAL PROVIDES INFORMATION AND INCLUDES COMMUNITY CARE PROGRAM MATERIALS WITH CORRESPONDENCE. SOCIAL SERVICES AND BUSINESS OFFICE STAFF AT THE HOSPITAL ARE ALSO AVAILABLE TO PROVIDE INFORMATION TO PATIENTS ON OTHER GOVERNMENT PROGRAMS SUCH AS THE MEDICAID PROGRAM OR TO REFER PATIENTS TO PERSONNEL AT RICHLAND COUNTY OR OTHER STATE OF WISCONSIN OR COUNTY AGENCIES THAT MAY PROVIDE ACCESS TO CARE. PART VI, LINE 4: THE RICHLAND HOSPITAL, INC. IS LOCATED IN RICHLAND CENTER, WISCONSIN, WHICH IS A COMMUNITY OF APPROXIMATELY 5,000 PEOPLE AND IS LOCATED 50 MINUTES FROM MADISON, WISCONSIN. THE FACILITY OPERATES A 25-BED, ACUTE CARE CRITICAL ACCESS HOSPITAL AND TWO RURAL HEALTH CLINICS LOCATED IN NEIGHBORING COMMUNITIES. THE RICHLAND HOSPITAL OFFERS A WIDE VARIETY OF SERVICES IN ORDER TO FULFILL MANY OF THE NEEDS OF THE INDIVIDUALS IN THE LOCAL COMMUNITY. AMONG SERVICES PROVIDED ARE: DIAGNOSTIC CARE, 24-HOUR EMERGENCY ROOM, OBSTETRICS, REHABILITATION, SURGICAL CARE, AND DIABETES SELF-CARE PROGRAMS, ALONG WITH OTHER SPECIALTY SERVICES, WHICH INCLUDE: AUDIOLOGY, CARDIOLOGY, ORTHOPEDICS, CHEMOTHERAPY, CLINICAL SERVICES, AMONG OTHERS. CARE IS OFFERED TO PATIENTS REGARDLESS OF PAY SOURCE AND REGARDLESS OF A PATIENT'S ABILITY TO PAY. THE COMMUNITIES SERVED BY THE RICHLAND HOSPITAL ARE DEFINED BY THE FOLLOWING ZIP CODES: 53506 - AVOCA53556 - LONE ROCK53518 - BLUE RIVER53573 - MUSCODA53581 - RICHLAND CENTER53588 - SPRING GREENTHEY ARE GEOGRAPHICALLY CONTIGUOUS COMMUNITIES. ACCORDING TO 2018 DATA PUBLISHED BY INTELLIMED, THE RICHLAND HOSPITAL, INC. HAD AN OVERALL INPATIENT MARKET SHARE OF 40.7 PERCENT AND OUTPATIENT MARKET SHARE OF 35.02 PERCENT IN THESE ZIP CODES. NO OTHER HEALTHCARE PROVIDER PROVIDING THE SAME SERVICES HAD A MARKET SHARE AS HIGH AS OR HIGHER THAN THE RICHLAND HOSPITAL, INC. (INTELLIMED COMBINES STATEWIDE HEALTHCARE DATA FROM WISCONSIN HOSPITAL ASSOCIATION IN A WEB-BASED SUPPORT ENGINE THAT ALLOWS US TO ANALYZE OUR MARKET.)SOCIO-DEMOGRAPHIC PROFILE OF THE MARKET AREA SERVED BY THE RICHLAND HOSPITAL, INC. SERVES PERSONS WHO ARE REPRESENTATIVE OF THE POPULATION OF THE MARKET AREA. A HIGHER PERCENTAGE OF THE POPULATION SERVED IS ELDERLY; THIS IS DUE TO THE FACT THAT PERSONS 65 YEARS OF AGE AND OLDER ARE HOSPITALIZED AT NEARLY THREE TIMES THE OVERALL RATE. SOME THINGS TO NOTE RELATED TO PLANNING FOR MEETING COMMUNITY HEALTH NEEDS INCLUDES THE FOLLOWING:- THE OVERALL POPULATION OF THE MARKET AREA IS PROJECTED TO REMAIN VERY STABLE, WITH NEGLIGIBLE GROWTH OR DECLINE PROJECTED OVER THE NEXT FIVE YEARS.- THE RESIDENTS OF THE MARKET AREA ARE AGING SIGNIFICANTLY. THERE IS A PROJECTED 29.2% GROWTH IN THE POPULATION AGED 75 TO 79 AND A PROJECTED 14.0% GROWTH IN THE POPULATION AGED 80-84. THERE IS A CORRESPONDING 20.6% PROJECTED DECLINE IN THE 25 TO 29 YEAR OLD POPULATION, 15.2 PERCENT DECLINE IN THE 55-59 YEAR OLD POPULATION AND 12.6 PERCENT DECLINE IN 20 TO 24 YEAR OLD POPULATION. PERSONS IN THE 0 TO 14 AGE GROUP ARE ALSO PROJECTED TO DECREASE BY 3.5%.DURING 2019, MEDICARE AND MEDICARE ADVANTAGE PLAN BENEFICIARIES ACCOUNTED FOR OVER 56 PERCENT OF ALL GROSS PATIENT SERVICE REVENUE AT THE RICHLAND HOSPITAL, INC. AND MEDICAID BENEFICIARIES ACCOUNTED FOR APPROXIMATELY 13 PERCENT OF ALL GROSS PATIENT SERVICE REVENUE. MEDICARE AND MEDICAID BENEFICIARIES MADE UP THE LARGEST PORTION OF PATIENTS THAT ARE SERVED BY THE RICHLAND HOSPITAL, INC. OVER THE PREVIOUS FEW YEARS. PART VI, LINE 5: THE RICHLAND HOSPITAL, INC. IS ACCREDITED THROUGH THE JOINT COMMISSION ("TJC"). THE TJC IS AN ORGANIZATION THAT EVALUATES HOSPITAL PERFORMANCE STANDARDS, FOCUSING ON THE QUALITY OF HEALTHCARE. ACCREDITATION THROUGH THE JOINT COMMISSION IS RECOGNIZED NATIONWIDE AS A SYMBOL OF QUALITY, AS IT REQUIRES RIGOROUS PERFORMANCE STANDARDS. TO EARN AND MAINTAIN ACCREDITATION, THE HOSPITAL IS EVALUATED THROUGH AN UNANNOUNCED SURVEY PROCESS COVERING NEARLY 600 STANDARDS RELATED TO QUALITY PATIENT CARE, SAFETY, INFECTION CONTROL, AND ONGOING PERFORMANCE-IMPROVEMENT ACTIVITIES, AMONG OTHERS. ALL HOSPITALS SURVEYED BY THE JOINT COMMISSION ARE EVALUATED AGAINST THE SAME CRITERIA, REGARDLESS OF SIZE OR LOCATION.THE ACTIVITIES OF THE RICHLAND HOSPITAL, INC. ARE SUPPORTED LOCALLY BY A VOLUNTEER BOARD OF DIRECTORS WHICH OVERSEE THE OPERATIONS OF THE HOSPITAL. THE BOARD OF DIRECTORS IS MADE UP OF COMMUNITY MEMBERS THAT RESIDE IN RICHLAND CENTER, WI, AND THE SURROUNDING AREA WHICH IS THE HOSPITAL'S PRIMARY PATIENT SERVICE AREA. THE HOSPITAL ALSO EXTENDS MEDICAL STAFF PRIVILEGES TO A MAJORITY OF ALL QUALIFIED PHYSICIANS IN THE COMMUNITY AND SURROUNDING AREAS WHO WISH TO BETTER SERVE THEIR PATIENTS BY PROVIDING CARE AT THE RICHLAND HOSPITAL, INC.ANY SURPLUSES IN OPERATIONS THAT ARE ACHIEVED BY THE HOSPITAL OPERATING IN AN EFFECTIVE MANNER AND CONTROLLING THE COST OF HEALTHCARE ARE PRIMARILY RESERVED FOR FUTURE BUILDING AND CAPITAL PURCHASE NEEDS. THE RICHLAND HOSPITAL, INC. RECOGNIZES THAT IT IS IMPORTANT TO SAVE THESE RESERVES DURING YEARS OF SURPLUS SO THAT IN TIMES OF ECONOMIC DOWNTURN, IF A LARGE CAPITAL ADDITION IS NEEDED, THE HOSPITAL WILL NOT HAVE TO PASS HIGHER COSTS ON TO MEMBERS OF THE COMMUNITY. THE HOSPITAL FURTHER ACHIEVES ITS GOAL OF PROVIDING TRUE COMMUNITY SUPPORT BY PROVIDING CHARITY CARE AS DESCRIBED THROUGHOUT SCHEDULE H AND PROVIDING SERVICES TO MEMBERS OF OTHER PROGRAMS WHICH OFTEN REIMBURSE THE HOSPITAL BELOW THE COST OF PROVIDING THIS CARE SUCH AS CHAMPUS, TRICARE, AND THE WISCONSIN HEALTH INSURANCE RISK SHARING PROGRAM OR "HIRSP" (THE HIRSP PROGRAM REIMBURSES THE HOSPITAL AT RATES SIMILAR TO THE MEDICAID PROGRAM AND IS FOR PATIENTS THAT HAVE PRE-EXISTING ILLNESSES WHICH MAKE IT DIFFICULT TO OBTAIN INSURANCE FROM COMMERCIAL INSURANCE CARRIERS IN THE MARKETPLACE). PART VI, LINE 7, REPORTS FILED WITH STATES WI X X X X 0 0 0 0 0 0 0 0 0 THOMAS BECK ORTHOPEDIC SURGEON 445056 0 125100 0 3853 0 11600 0 17315 0 602924 0 0 0 ANDREW WRIGHT FAMILY DOCTOR 278186 0 93057 0 3320 0 11600 0 33442 0 419605 0 0 0 BRYAN MCCARVEL CRNA 385310 0 5000 0 1920 0 0 0 10774 0 403004 0 0 0 ANDREW HARRIS ER MD DOCTOR 341883 0 0 0 3853 0 11600 0 39576 0 396912 0 0 0 SHAWN O' BRIEN EMERGENCY PHYSICIAN 329726 0 12500 0 2463 0 7126 0 39462 0 391277 0 0 0 BRUCE ROESLER CEO 288533 0 28500 0 3717 0 11600 0 30387 0 362737 0 0 0 CHRISTINE RICHARDS MD CHIEF OF STAFF 204303 0 95935 0 2757 0 11600 0 17144 0 331739 0 0 0 KAY BALINK MD DIRECTOR (& EMPLOYEE) 147703 0 39075 0 2223 0 7821 0 32345 0 229167 0 0 0 JEFFERY LONGBRAKE INTERIM CFO (THRU AUG) 190590 0 0 0 0 0 0 0 0 0 190590 0 0 0 FORM 990, PART VI, SECTION B, LINE 11B A COPY OF FORM 990 WAS EMAILED OR MAILED TO ALL MEMBERS OF THE HOSPITAL'S BOARD OF DIRECTORS BEFORE IT WAS FILED. ALL BOARD MEMBERS WERE GIVEN THE OPPORTUNITY TO RESPOND WITH COMMENTS PRIOR TO THE FINAL SUBMISSION OF THE FORM 990 TO THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C THE RICHLAND HOSPITAL, INC. REQUIRES ALL OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES TO COMPLETE ITS ANNUAL DISCLOSURE STATEMENT. THESE QUESTIONNAIRES ARE THEN REVIEWED BY THE BOARD OF DIRECTORS, NOTING ANY RELATIONSHIPS THAT COULD POTENTIALLY CREATE A CONFLICT OF INTEREST. ANY INDIVIDUALS WITH NOTED CONFLICTS ARE ASKED TO ABSTAIN FROM VOTING OR ACTING ON THOSE MATTERS. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF DIRECTORS HAS AN ESTABLISHED PROCESS TO ANNUALLY REVIEW THE COMPENSATION FOR THE CHIEF EXECUTIVE OFFICER AND TO DEFINE APPROPRIATE MARKET AND PERFORMANCE-BASED ADJUSTMENTS. COMPARATIVE DATA IS OBTAINED FROM EITHER THE WISCONSIN HOSPITAL ASSOCIATION EXECUTIVE COMPENSATION SURVEY OR OTHER REPUTABLE THIRD-PARTY HEALTHCARE DATA SOURCES TO USE IN THE ESTABLISHMENT OF A MARKET FOR THIS KEY POSITION. THE PERSONNEL COMMITTEE OF THE BOARD OF DIRECTORS FULFILLS THIS ROLE. THE BOARD OF DIRECTORS HAS DELEGATED THE AUTHORITY AND RESPONSIBILITY FOR THE ONGOING MAINTENANCE OF OTHER KEY EMPLOYEES AND THE OVERALL ORGANIZATIONAL COMPENSATION MODEL TO THE CHIEF EXECUTIVE OFFICER AND HUMAN RESOURCE DIRECTOR. COMPARATIVE MARKET DATA IS OBTAINED VIA THE RURAL WISCONSIN HEALTH COOPERATIVE AND THE WISCONSIN SOCIETY OF HOSPITAL HUMAN RESOURCE ADMINISTRATORS VIA INDEPENDENT SALARY SURVEYS THAT PROVIDE BENCHMARK INFORMATION FOR HEALTHCARE JOB CLASSES. THIS DATA IS USED TO ESTABLISH SALARY RANGES FOR ALL JOB CLASSES WITHIN THE ORGANIZATION. THE BOARD OF DIRECTORS ANNUALLY AUTHORIZES THE OVERALL INCREASE TO THE SALARY BUDGET FOR THE ORGANIZATION WITH THE CEO MAINTAINING DELEGATED AUTHORITY FOR IMPLEMENTATION WITHIN THE ORGANIZATIONAL COMPENSATION MODEL. DURING THE REVIEW PROCESS, DECISIONS AFFECTING COMPENSATION AND CONTRACTS ARE ONLY REVIEWED AND APPROVED BY INDIVIDUALS WHO DO NOT HAVE NOTED CONFLICTS. FORM 990, PART VI, SECTION C, LINE 19 THE RICHLAND HOSPITAL, INC. MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST AT ITS HOSPITAL BUSINESS LOCATION DURING NORMAL BUSINESS HOURS. FORM 990, PART VII, SECTION A CHRISTINE RICHARDS IS ON THE BOARD OF DIRECTORS AS A VOTING MEMBER, SHE IS ALSO CONSIDERED A FULL TIME EMPLOYEE AS CHIEF OF STAFF. THEIR COMPENSATION REPORTED IN PART VII, SECTION A REFLECTS THEIR ROLE AS CHIEF OF STAFF. $11,700 IS TOWARDS HER ROLE THAT DOES INCLUDE CERTAIN BOARD DUTIES. KAY BALINK IS ALSO ON THE BOARD OF DIRECTORS. THE COMPENSATION REPORTED REFLECTS ONLY HER ROLE AS AN EMPLOYEE AND SHE RECEIVES NO COMPENSATION FOR HER TIME DEVOTED TO THE BOARD OF DIRECTORS. FORM 990, PART IX, LINE 11G OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,116,763. MANAGEMENT AND GENERAL EXPENSES 1,621,813. FUNDRAISING EXPENSES 1,239. TOTAL EXPENSES 2,739,815. MEDICAL IMAGING PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 2,782,265. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,782,265. CLINICAL PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 93,550. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 93,550. LABORATORY PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 544,310. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 544,310. SURGICAL PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 117,940. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 117,940. HOSPITALIST PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 845,692. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 845,692. BEHAVIORAL HEALTH PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 555,395. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 555,395. FORM 990, PART XI, LINE 9: NET CHANGE IN RESTRICTED NET ASSETS OF SUPPORTING ORGANIZATIONS 109,762. NET CHANGE IN UNRESTRICTED NET ASSETS OF SUPPORTING ORGANIZATIONS -468,538. INCREASE IN EQUITY OF UNCONSOLIDATED AFFILIATE 532,416. RICHLAND HOSPITAL FOUNDATION INC 333 EAST SECOND STREET RICHLAND CENTER WI 53581 391567249 FOUNDATION WI 501(C)(3) LINE 7 N/A 0 PARTNERS OF RICHLAND HOSPITAL INC 333 EAST SECOND STREET RICHLAND CENTER WI 53581 391693458 AUXILIARY WI 501(C)(3) LINE 10 N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 RICHLAND HOSPITAL FOUNDATION C 105810 CASH