2021-11-15T16:42:58-06:00 2020-12-31 ERNST & YOUNG US LLP 155 N Wacker Drive Chicago IL 60606 990 2020-01-01 390944012 MOUNDVIEW MEMORIAL HOSPITAL & CLINICS % FRANK PEREZ-GUERRA MOUN 6083393331 402 WEST LAKE STREET FRIENDSHIP WI 53934 FRANK PEREZ-GUERRA CEO 6083393331 2021-11-15 true FRANK PEREZ-GUERRA 999009999 JESS WAGENER P01622613 3128792000 2021-11-15 3 2020 2022-09-23 18:48:47Z GUNDERSEN MOUNDVIEW HOSP AND CLINICS FRANK PEREZ-GUERRA 402 WEST LAKE STREET FRIENDSHIP WI 53934 20677262 false X WWW.GUNDERSENHEALTH.ORG/MOUNDVIEW/ X 1959 WI WE WILL ENHANCE THE HEALTH AND WELL-BEING OF OUR COMMUNITIES WHILE ENRICHING EVERY LIFE WE TOUCH, INCLUDING PATIENTS, FAMILIES, AND STAFF. 8 3 162 65 0 104548 714119 18470787 19640027 76067 99864 140327 210302 18791729 20664312 1250 1100 0 0 8952679 9348389 0 0 0 9318108 9188772 18272037 18538261 519692 2126051 12862094 20739931 3650365 9378738 9211729 11361193 WE WILL DISTINGUISH OURSELVES THROUGH EXCELLENCE IN PATIENT CARE, EDUCATION, AND IMPROVED HEALTH IN THE COMMUNITIES WE SERVE. false false 15613888 1100 19728983 THE HOSPITAL IS A GENERAL MEDICAL CRITICAL ACCESS HOSPITAL LICENSED FOR 25 BEDS. DURING FISCAL YEAR 2020, THE HOSPITAL HAD 322 ACUTE INPATIENT DAYS AND 465 SKILLED NURSING DAYS (SWING BED). THE HOSPITAL ALSO HAD 5,613 EMERGENCY ROOM/URGENT CARE VISITS. 15613888 true true false true false false false false false true false false false true true false true false false false false false false false false true true false false true false false false false false false false false false false false false false true false true false true 190 0 162 false false false false false false false false false false false false false X 8 3 false false false false true true true true true false false false true true true true true true false false WI X FRANK PEREZ-GUERRA 6083393331 402 WEST LAKE FRIENDSHIP WI 53934 STEPHANIE CARROL BOARD TRUSTEE 2.5 40.0 X 0 336927 55034 BRYAN ERDMAN BOARD TRUSTEE 2.5 40.0 X 0 267169 60881 FRANK PEREZ-GUERRA CEO 1.0 40.0 X 0 171289 47178 ROXANNE POTTS BOARD TRUSTEE 2.5 40.0 X 0 125642 35393 HEATHER GREILING NURSE PRACTICIONER 40.0 0.0 X 125788 0 34966 DIANA BRONIAC DIRECTOR 40.0 0.0 X 150644 0 5845 PAUL FISCH VICE CHAIR 2.5 40.0 X X 0 113535 38507 SARAH ROSSMAN SECRETARY 2.5 40.0 X X 0 127439 21026 JUDY NOWICKI DIRECTOR 40.0 0.0 X 125065 0 14707 LINDA CHARLES NURSE PRACTICIONER 40.0 0.0 X 124202 0 14192 LORI WITTIG DIRECTOR 40.0 0.0 X 116206 0 7051 MICHAEL CUMMINGS BOARD MEMBER 2.5 0.0 X 0 0 0 RIHCARD STERNHAGEN CHAIR 2.5 0.0 X X 0 0 0 RENEE SCHINDLBECK TREASURER 2.5 0.0 X X 0 0 0 641905 1142001 334780 11 false true false GUNDERSEN HEALTH SYSTEM 1900 SOUTH AVENUE LA CROSSE WI 54601 ADMINISTRATIVE SVCS 3064645 EMCARE PHYSICIAN SERVICES PO BOX 972633 DALLAS TX 753972633 PROVIDER COVERAGE 1519251 WEATHERBY HEALTHCARE 221 W COLLEGE AVE FLR 2 APPLETON WI 549115759 CONTRACT NURSING SVC 339330 FIRST REFLECTIONS INC 228 N PINE STREET ADAMS WI 53910 CRNA SERVICES 225378 SHARED IMAGING SERVICES PO BOX 88450 MILWAUKEE WI 532880450 NUCLEAR MED/EKG SVCS 173918 5 60133 653986 714119 NET PATIENT SERVICE REVENUE 621300 19564274 19564274 0 0 MEDICAL BUILDING RENT 531120 64700 64700 0 0 NURSING PROGRAMS & VACCINE ADIM 623000 11053 11053 0 0 19640027 99864 0 0 99864 0 0 22356 12950 9406 0 9406 0 0 9406 0 0 0 0 0 0 0 0 0 0 E.H.R. INCENTIVE 900099 88956 88956 0 0 ALL OTHER REVENUE 900099 111940 0 0 111940 200896 20664312 19728983 0 221210 X 1100 1100 0 0 0 218467 0 218467 0 0 7244058 5916532 1327526 0 137942 104214 33728 0 1233776 944607 289169 0 514146 418785 95361 0 0 24962 0 24962 0 48600 0 48600 0 1709 0 1709 0 0 0 4952488 4595009 357479 0 61251 3400 57851 0 472436 355579 116857 0 567 504 63 0 0 280612 256676 23936 0 37728 35125 2603 0 0 31648 17264 14384 0 48836 30523 18313 0 0 673983 587060 86923 0 57117 0 57117 0 MEDICAL SUPPLIES 1115624 1115624 0 0 BAD DEBT EXPENSE 895559 810389 85170 0 REPAIRS & MAINTENANCE 266915 202760 64155 0 MISCELLANEOUS 218737 218737 0 0 18538261 15613888 2924373 0 700 700 2954609 12065743 0 0 2237422 2167154 0 0 0 0 0 0 241475 208427 214447 79884 7658552 2082806 6085331 5575746 0 0 0 0 0 0 0 0 1128110 642277 12862094 20739931 1749773 4661822 0 0 3090 1634701 0 0 0 0 0 0 1866561 169632 0 0 30941 2912583 3650365 9378738 X 8659560 10785611 552169 575582 9211729 11361193 12862094 20739931 2126051 23413 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 1709 1709 false PART II-B, LINE 1, LOBBYING ACTIVITIES MOUNDVIEW MEMORIAL HOSPITAL & CLINICS 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 HAS NOTIFIED MOUNDVIEW MEMORIAL HOSPITAL & CLINICS THAT $1,709 OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. 76500 76500 5280928 757509 4523419 2233715 1325297 908418 67409 67409 5575746 0 OPERATING LEASE LIABILITIES 27231 DUE TO THIRD PARTY PAYROS 1129615 PENSION PLAN LIABILITIES 17466 DEFERRED REVENUE 1738271 2912583 X true true X true X true X true true true false true true 33762 0 33762 0.00190 2605835 1708004 897831 0.05110 0 0 0 0.00000 2639597 1708004 931593 0.05300 107504 2985 104519 0.00600 8541 0 8541 0.00050 116045 2985 113060 0.00650 2755642 1710989 1044653 0.05950 true 308957 12868 7313266 7356711 -43445 X true true 1 1 MOUNDVIEW MEMORIAL HOSPITAL 402 WEST LAKE STREET FRIENDSHIP WI 53934 WWW.GUNDERSENHEALTH.ORG/MOUNDVIEW 1014 X X X X MOUNDVIEW MEMORIAL HOSPITAL 1 false false true X X X X X X X X X 18 false false true true X SEE SUPPLEMENTAL INFO X true 18 true SEE SUPPLEMENTAL INFO false true X 200. 400. X X X X true true X X X X true X SEE SUPPLEMENTAL INFORMATION X SEE SUPPLEMENTAL INFORMATION X SEE PART V, PAGE 8 X X X X X X true X false X X X X true X false false SHEDULE H, PART V, SECTION B, LINE 5 THE HOSPITAL COLLABORATED WITH THE ADAMS COUNTY PUBLIC HEALTH, UW EXTENSION, ADAMS COUNTY GOVERNMENT, ADAMS-FRIENDSHIP SCHOOL DISTRICT AND COMMUNITY MEMBERS TO CREATE AND CONDUCT A HEALTH SURVEY OF THE GENERAL PUBLIC IN MARCH 2016. THERE WERE 602 RESPONDENTS, MAKING IT A STATISTICALLY SIGNIFICANT SAMPLE OF THE COUNTY. THE SURVEY WAS WIDELY DISTRIBUTED VIA A SURVEY LINK SHARED THROUGH ORGANIZATION EMAIL LISTS, ORGANIZATION FACEBOOK PAGES, AREA NEWSLETTERS, NEWSPAPER AND RADIO. INDIVIDUALS WERE LIMITED TO ONE SURVEY PER EMAIL ADDRESS. PAPER SURVEYS WERE DISTRIBUTED THROUGH FOOD PANTRIES, LIBRARY, MEALS ON WHEELS, SENIOR MEAL SITES, AND THE LIGHTED SCHOOL HOUSE PROGRAM TO OBTAIN INPUT FROM THOSE WITHOUT COMPUTERS AND OTHER DIFFICULT TO REACH POPULATIONS. SURVEY RESPONDENTS WERE ASKED TO RANK ISSUES THAT MAY IMPACT THEIR COMMUNITY'S HEALTH ON A SEVEN POINT SCALE AND TO NAME THEIR TOP TWO HEALTH CONCERNS. A SIMLIAR SUVEY WAS DISTRIBUTED VIA EMAIL TO 43 COMMUNITY STAKEHOLDERS WHO WERE IDENTIFIED AS HAVING A BROAD, VESTED INTEREST IN THE COMMUNITY. THESE INCLUDED MEDICAL PROVIDERS AND PROFESSIONALS, SERVICE AGENCIES (INCLUDING THOSE REPRESENTING LOW INCOME AND DISABILITY POPULATIONS), SCHOOL LEADERS, COUNTY GOVERNMENT, BUSINESS LEADERS AND OTHER OFFICIALS. COMMUNITY STAKEHOLDER AND PATIENT ADVISORY COUNCIL FOCUS GROUPS WERE HELD IN 2018 TO REVIEW AND PRIORITIZE SEVEN IDENTIFIED NEEDS. SCHEDULE H, PART V, SECTION B, LINE 6B WHILE THE NEEDS ASSESSMENT IS SPECIFIC TO GUNDERSEN MOUNDVIEW, THE HOSPITAL COLLABORATED WITH OTHER ORGANIZATIONS IN OBTAINING AND ANALYZING DATA INCLUDING ADAMS COUNTY PUBLIC HEALTH AND THE BE HEALTHY ADAMS COUNTY COALITION WHICH INCLUDED REPRESENTATIVES FROM ADAMS COUNTY GOVERNMENT, ADADMS-FREINDSHIP SCHOOL DISTRICT AND COMMUNITY MEMBERS AT LARGE. SCHEDULE H, PART V, SECTION B, LINE 7 https://www.gundersenhealth.org/app/files/public/abf2ab60-b046-458c-867a-5 2877b894024/community-needs-assessment-2018-moundview.pdf SCHEDULE H, PART V, SECTION B, LINE 10 https://www.gundersenhealth.org/app/files/public/6ebf8f47-5565-47a1-98e4-a ca407f672a2/community-needs-implementation-plan-2019-moundview.pdf SCHEDULE H, PART V, SECTION B, LINE 11 GUNDERSEN MOUNDVIEW CONTINUES TO ADDRESS IDENTIFIED HEALTH NEEDS THROUGH OUR IMPLEMENTATION PLAN. "CHRONIC DISEASE AND CONDITIONS" ARE ADDRESSED BY OUR PARTICIPATION IN VARIOUS COALITIONS AND EVENTS. SOME EXAMPLES INCLUDE: BE HEALTHY ADAMS COUNTY COALITIONS - WHICH ESTABLISHES INITATIVES TO INCREASE AND IMPROVE PHYSICAL ACTIVITY AND NUTRITION, SPONSORSHIP OF AREA FORM MARKETS TO IMPROVE ACCESS TO FRUITS/VEGETABLES, PARTICIPATING ON THE YMCA STEERING COMMITTEE WHICH IS WORKING ON THE ESTABLISHMENT OF A SATELLITE YMCA IN OUR COUNTY, ADAMS COUNTY CANCER AWARENESS TEAM PROMOTING AWARENESS OF CANCER AND RELATED SCREENINGS, AND SPONSORSHIPS/PARTICIPATION IN ADAMS COUNTY SUICIDE AWARENESS COALITION. WE HAVE INCREASED OUR NUMBER OF MENTORS IN THE ELEMENTARY SCHOOL BY 45% (FROM 20 TO 29 MENTORS) OVER THE PRIOR YEAR. MENTORS HELP BUILD YOUTH RESILIENCY BY MITIGATING THE IMPACT OF ADVERSE CHILDHOOD EXPERIENCES. WE IMPLEMENTED SAFE SITTER AND HOME ALONE CLASSES TO ASSIST FAMILIES WHOS CHILDREN ARE HOME ALONE WHIL PARENTS ARE WORKING. WE ARE IN THE PLANNING STAGES OF IMPLEMENTING A GRIEF SUPORT GROUP - A NEED THAT WAS IDENTIFIED THROUGH COLLABORATIVE WORK WITH THE AGING DEPARTMENT. WE CONTINUE TO ADDRESS "SUBSTANCE ABUSE" THROUGH OUR SUPPORT/COLLABORATION WITH FAMILY HEALTH LA CLINICA ROCHE-A CRI BEHAVIORAL HEALTH AND RECOVERY CENTER WHICH INCLUDES SERVING ON THEIR COMMITTEE. WE CONTINUE TO SERVE ON THE DRUG FREE COALITION AND PROMOTE DRUG TAKE BACK EVENTS. WE PROVIDE LAB SUPPORT (OVER 542 DRUG COLLECTIONS IN 2019 ALONE) TO THE COUNTY DRUG TREATMENT COURT. HEALTH CARE COST AND ACCESS IS CONTINNUALLY ADDRESSED. SEVERAL NEW SPECIALTY PROVIDERS WERE ADDED IN 2019 AND ARE NOW SEEING PATIENTS LOCALLY. WE RECRUITED A NEW NURSE PRACTICIONER TO PRIMARY CARE. THERE REMAINS A NEED TO CONTINUE RERUITMENT IN BOTH AREAS. THROUGH SHARED RESOURCES VIA OUR AFFILIATION WITH GUNDERSEN, WE CONTINUE TO SEE COST SAVINGS THROUGHOUT OUR ORGANIZATION. WORKBOFRE DEVELOPEMENT HAS BEEN ADDRESSED BY PARTICPATING ON THE COUNTY ECONOMIC DEVELOPMENT COUNCIL, CHAMBER OF COMMERCE BOARD, AND THE NEW UNIVERSITY ALLIANCE COALITION. WE PROVIDED CLINICAL ROTATIONS/INTERNSHIP OPPORTUNITIES TO 15 STUDENTS IN 2019. WE CONTINUE TO PROVIDE EDUCATIONS AND TUITION REIMBRUSEMENT PROGRAMS FOR OUR STAFF. SCHEDULE H, PART V, SECTION B, LINE 13H HOSPITAL PATIENTS NOT MEETING FINANCIAL ASSISTANCE ELIGIBILITY THRESHOLDS MAY BE ELIGIBLE FOR ASSISTANCE UNDER CIRCUMSTANCES WHEN HOSPITAL MEDICAL BILLS WOULD RESULT IN SEVERE FINANCIAL HARDSHIP. PATIENTS, OR THEIR GUARANTORS, MAY BE ELIGIBLE FOR CATASTROPHIC CARE ASSISTANCE IF THEY HAVE INCURRED OUT-OF-POCKET OBLIGATIONS RESULTING FROM MEDICAL SERVICES PROVIDED BY GMV THAT EXCEED 25% OF FAMILY INCOME AND HAVE ASSETS BELOW THE EQUIVALENT OF 600% OF THE FPL THRESHOLD. SCHEDULE H, PART V, LINE 16A FAP WEBSITE: HTTPS://WWW.GUNDERSENHEALTH.ORG/APP/FILES/PUBLIC/8939/FINANCIAL-ASSISTANCE -MOUNDVIEW-FAP-FINANCIAL-ASSISTANCE-POLICY.PDF SCHEDULE H, PART V, LINE 16B FAP APPLICATION WEBSITE: HTTPS://WWW.GUNDERSENHEALTH.ORG/APP/FILES/PUBLIC/8946/FINANCIAL-ASSISTANCE -ALL-LOCATIONS-FINANCIAL-ASSISTANCE-APPLICATION-ENGLISH.PDF SCHEDULE H, PART V, LINE 16C FAP PLAIN LANGUAGE SUMMARY WEBSITE: HTTPS://WWW.GUNDERSENHEALTH.ORG/APP/FILES/PUBLIC/8936/FINANCIAL-ASSISTANCE -MOUNDVIEW-PLAIN-LANGUAGE-SUMMARY.PDF 2 GUNDERSEN FRIENDSHIP CLINIC 402 WEST LAKE STREET FRIENDSHIP WI 53934 RURAL HEALTH CLINIC GUNDERSEN WESTFIELD CLINIC 207 NORTH PIONEER PARK ROAD WESTFIELD WI 53964 RURAL HEALTH CLINIC SCHEDULE H, PART I, LINE 7 THE RATIO OF PATIENT COST TO CHARGES WAS CALCULATED BY DIVIDING HOSPITAL EXPENSES NET OF NON-PATIENT REVENUE AND IDENTIFIED COMMUNITY BENEFIT EXPENSE BY GROSS PATIENT REVENUE. SCHEDULE H, PART I, LINE 7G THE ORGANIZATION OPERATES 2 RURAL HEALTH CLINICS, AN OBSERVATION ROOM AND EMERGENCY ROOM WHERE THE COSTS EXCEED THE NET PATIENT SERVICE REVENUE. THESE SERVICES WOULD NOT BE PROVIDED TO THE COMMUNITY IF NOT FOR THE LEADERSHIP OF THE HOSPITAL. THE ORGANIZATION UTILIZED THEIR COST REPORT AND OTHER INTERNAL INFORMATION TO DETERMINE THE AMOUNTS TO BE RECORDED PER WORKSHEET 6 OF THE IRS FORM SCHEDULE H INSTRUCTIONS. AMOUNTS RECORDED HERE HAVE NOT BEEN DUPLICATED IN OTHER AREAS OF THE FORM. MEDICAID, BAD DEBT, FINANCIAL ASSISTANCE HAS BEEN REMOVED FROM THE AMOUNTS REPORTED AND THESE SERVICES WERE EXCLUDED FROM THE MEDICARE SURPLUS/SHORTFALL CALCULATION. SCHEDULE H, PART II COMMUNITY BUILDING ACTIVITIES: THE HOSPITAL'S COMMUNITY BUILDING ACTIVITES PROMOTES HEALTH OF THE COMMUNITIES IT SERVES THROUGH LOCAL ADVERTISEMENTS, INVOLVEMENT WITH CHAMBER OF COMMERCE, DEPARTMENT OF AGING AND OTHER COMMUNITY ORGANIZATIONS. THE AMOUNT OF SUPPORT IS DIFFICULT TO QUANTIFY. SCHEDULE H, PART III, LINE 2 THE RATIO OF PATIENT COST TO CHARGES WAS CALCULATED BY DIVIDING HOSPITAL EXPENSES NET OF NON-PATIENT REVENUE AND IDENTIFIED COMMUNITY BENEFIT EXPENSE BY GROSS PATIENT REVENUE. THE PERCENTAGE WAS THEN MULTIPLIED BY THE GROSS REVENUES ON BAD DEBT ACCOUNTS. SCHEDULE H, PART III, LINE 3 IT IS CONSIDERED COMMUNITY BENEFIT AS THE HOSPITAL IS REIMBURSED ON MEDICARE ALLOWABLE COSTS. MEDICARE ALLOWABLE COSTS ARE DEFINED BY MEDICARE. THEY DO NOT NEESSARILY CAPTURE ALL COSTS OF THE HOSPITAL PROVIDING SERVICES TO THE COMMUNITY. CONSEQUENTLY, THERE ARE COSTS NOT REIMBURSED BY EITHER PATIENT OR THE PROGRAM. SCHEDULE H, PART III, LINE 4 PATIENT ACCOUNTS RECEIVABLE ARE RECORDED IN THE ACCOMPANYING CONSOLIDATED BALANCE SHEETS NET OF CONTRACTUAL ADJUSTMENTS AND AN ALLOWANCE FOR DOUBTFUL ACCOUNTS, THAT REFLECTS MANAGEMENT'S BEST ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECCTED. MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH A REDUCTION OF GROSS PATIENT SERVICE REVENUE AND A CREDIT TO PATIENT ACCOUNTS RECEIVABLE. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY FROM UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLIE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND CURRENT STATUS OF INDIVIDUAL ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF PATIENT ACCOUNTS RECEIVABLE, THE ORGANIZATION 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 ORGANIZATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THRID-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCICATED 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 ORGANIZATION 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 EXAHUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. SCHEDULE H, PART III, LINE 8 IT IS CONSIDERED COMMUNITY BENEFIT AS THE HOSPITAL IS REIMBURSED ON MEDICARE ALLOWABLE COSTS. MEDICARE ALLOWABLE COSTS ARE DEFINED BY MEDICARE. THEY DO NOT NECESSARILY CAPTURE ALL COSTS OF THE HOSPITAL PROVIDING SERVICES TO THE COMMUNITY. CONSEQUENTLY, THERE ARE COSTS NOT REIMBURSED BY EITHER PATIENT OR THE PROGRAM. THE COST METHOLDOLGOY USED TO DETERMINE MEDICARE ALLOWABLE COSTS IS A STEP-DOWN ALLOCATION OF COSTS FROM NON-REVENUE AREAS TO REVENUE AREAS. THIS ALLOCATION IS DONE FOLLOWING MEDICARE RULES AND REGULATIONS. SCHEDULE H, PART III, LINE 9B PATIENTS UPON REGISTRATION ARE GIVEN THE POLICY AND REQUIREMENTS TO BE ELIGIBLE FOR CHARITY CARE. THEY ARE ENCOURAGED BY A FINANCIAL ADVISOR TO REVIEW THEIR SITUATION FOR ELIGIBILITY. SCHEDULE H, PART VI, LINE 2 THE HOSPITAL COLLECTS, REVIEWS AND ANALYZES LOCAL, REGIONAL AND STATE DATA SOURCES IN CONJUNCTION WITH THE LOCAL PUBLIC HEALTH DEPARTMENT TO ASSESS SPECIFIC UNMET COMMUNITY NEEDS. THIS DATA INCLUDES SURVEYS OF THE GENERAL COMMUNITY AS WELL AS COMMUNITY STAKEHOLDERS WITH A BROAD, VESTED INTEREST IN THE COMMUNITY. IT ALSO INCLUDES TWO FOCUS GROUP SESSIONS OF COMMUNITY STAKEHOLDERS AND THE HOSPITAL'S PATIENT ADVISORY COUNCIL TO REVIEW AND HELP PRIORITIZE HEALTH NEEDS. THE HOSPITAL ANNUALLY REVIEWS THE COUNTY HEALTH RANKINGS AS WELL AS INFECTION CONTROL/COMMUNICABLE DISEASE REPORTS WITH THE PUBLIC HEALTH OFFICE. SCHEDULE H, PART VI, LINE 3 THE HOSPITAL ANNUALLY UPDATES THE AVAILABILITY OF ITS CHARITY PLAN AND QUALIFYING INCOME NEEDS TO QUALIFY ON THE HOSPITAL WEBSITE. THE EXISTENCE OF A CHARITY PLAN IS POSTED IN THE ADMITTING AREA. UPON REGISTRATION, THE PATIENT IS INFORMED OF THE HOSPITAL'S CHARITY PLAN, ELIGIBLITY AND METHODS FOR APPLYING. ANYONE INTRESTED IN FURTHER INFORMATION IS REFERRED TO THE PATIENT ACCOUNT COORDINATOR FOR QUESTIONS AND ELIGIBILITY. THIS PERSON WORKS WITH THE PATIENT IN APPLICATION AS WELL AS EXPLORING THE POSSIBLE ELIGIBILITY OF ANY OTHER GOVERNMENT PROGRAM THAT MAY BE APPLICABLE, I.E. MEDICAID, BADGER CARE. SCHEDULE H, PART VI, LINE 4 THE ORGANIZATION SERVES ALL OF ADAMS COUNTY WISCONSIN (POPULATION APPROXIMATELY 19,973). ITS PRIMARY SERVICE AREA IS WITHIN THE CENTER OF THE COUNTY, BORDERED BY HWY 82 SOUTH, COUNTY C NORTH. THE COUNTY'S POVERTY RATE IS 13.9% HIGHER THAN THE STATE AVERAGE. OVER 70% OF STUDENTS ENROLLED IN THE SCHOOL DISTRICT ARE ELIGIBLE FOR FREE LUNCH. THE PERCENTAGE OF THOSE AGED 65 YEARS AND OVER IS 28%, WHICH IS SIGNIFICANTLY HIGHER THAN THE STATE AND IS PROJECTED TO STEADILY INCREASE TO GREATER THAN 35% BY 2040. THERE IS A LOWER LEVEL OF COLLEGE EDUCATED RESIDENTS THAN STATE AVERAGES. SCHEDULE H, PART VI, LINE 5 THE HOSPITAL WORKS WITH LOCAL PUBLIC HEALTH AND COMMUNITY SERVICE ORGANIZATIONS TO COORDINATE AND/OR PROVIDE SPONSORSHIP FUNDS TO SUPPORT COMMUNITY HEALTH PROGRAMS TO MEET THE NEEDS OF THE LOCAL COMMUNITY. THE HOSPITAL PROVIDES INKIND SUPPORT INCLUDING THE USE OF OUR MEETING ROOMS BY NONPROFIT GROUPS, DONATION OF EQUIPMENT/FURNITURE TO HABITAT FOR HUMANITY AND STAFF WHO SERVE ON NUMEROUS COMMUNITY COALITIONS AND HEALTH BOARDS. THE HOSPITAL BOARD INCLUDES COMMUNITY MEMBERS WHO ARE UNPAID. THE HOSPITAL ALSO PROVIDES SPONSORSHIPS OF EVENTS/PROGRAMS THAT HAVE HEALTH/WELLNESS EDUCATION BUILT INTO THEM. SCHEDULE H, PART VI, LINE 6 THE ORGANIZATION IS PART OF GUNDERSEN HEALTH SYSTEM. EACH AFFILIATE DEVELOPS ITS OWN NEEDS ASSESSMENT AND IMPLEMENTATION PLAN, WITH SUPPORT FROM THE SYSTEM AS NEEDED. THE SYSTEM HOLDS QUARTERLY COMMMUNITY BENEFIT MEETINGS AMONG THE AFFILIATES TO REVIEW PROGRESS ON GOALS. SCHEDULE H, PART VI, LINE 7 LIST OF STATES RECEIVING COMMUNITY BENEFIT REPORT: WI X X false false false false false false false false false STEPHANIE CARROL BOARD TRUSTEE 0 297121 0 2500 0 37306 0 35738 0 23676 0 396341 0 0 PAUL FISCH VICE CHAIR 0 107510 0 0 0 6025 0 16957 0 21550 0 152042 0 0 ROXANNE POTTS BOARD TRUSTEE 0 120387 0 0 0 5255 0 16043 0 19350 0 161035 0 0 BRYAN ERDMAN BOARD TRUSTEE 0 262558 0 0 0 4611 0 38960 0 25481 0 331610 0 0 FRANK PEREZ-GUERRA CEO 0 168280 0 0 0 3009 0 25278 0 21900 0 218467 0 0 DIANA BRONIAC DIRECTOR 148169 0 0 0 2475 0 4345 0 1500 0 156489 0 0 0 HEATHER GREILING NURSE PRACTICIONER 120932 0 0 0 4856 0 3903 0 31063 0 160754 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 ANY PERSON OVER THE AGE OF EIGHTEEN YEARS WHO IS A RESIDENT OF ADAMS COUNTY MAY BE A MEMBER OF THE CORPORATION. MEMBERSHIP MAY BE ATTAINED BY ANY SUCH PERSON WHO SHALL AGREE IN WRITING TO BECOME A MEMBER OF THIS CORPORATION BY SUBSCRIBING TO A MEMBERSHIP LIST OF SAID CORPORATION. ANNUAL MEMBERSHIPS WILL BE IN EFFECT FROM JULY 1ST TO JUNE 30TH OF EACH FISCAL YEAR. FORM 990, PART VI, SECTION A, LINE 7A EACH PERSON WHO WAS A MEMBER IN GOOD STANDING AS OF THE PREVIOUS JUNE 30TH IS ENTITLED TO ONE VOTE FOR EACH SEAT OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B MEMBERS OF THE ORGANIZATION MUST APPROVE BYLAW CHANGES. FORM 990, PART VI, SECTION B, LINE 11B THE 990 IS REVIEWED BY THE CEO PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY IS REVIEWED EVERY YEAR BY THE POLICY AND PROCEDURE COMMITTEE AND BY THE CEO. OFFICERS AND DIRECTORS ARE REQUIRED TO REVIEW THE POLICY AND DISCLOSE CONFLICTS. THE CEO REVIEWS THE SIGNED STATEMENTS. IF THERE IS A CONFLICT, THE CONFLICT WOULD BE DECLARED AND THE MEMBER WOULD ABSTAIN FROM VOTING. FORM 990, PART VI, SECTION B, LINE 15A CEO COMPENSATION IS BASED ON DIRECT NEGOTIATIONS BETWEEN THE BOARD MEMBERS WITHOUT CONFLICT AND THE INDIVIDUAL UTILIZING CURENT RELEVANT MARKET SURVEYS AS A GUIDE WITH THE LANGUAGE OF CONTRACT GIVEN TO MMHC ATTORNEYS FOR REVIEW AND COMMENTS. SUBSEQUENT MODIFICATIONS ARE PERFORMANCE BASED AND MARKET DRIVEN. FOR OTHER OFFICERS AND KEY EMPLOYEES, THE CEO DETERMINES SALARY BASED ON THE MARKET, EXPERIENCE, AND INDUSTRY SRUVEY GUIDES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION BELIEVE THE GOVERNING DOCUMENTS AND POLICIES ARE THE PROPERTY OF THE ORGANIZATION AND ARE NOT AVAILABLE FOR PUBLIC INSPECTION. THE AUDITED FINANCIAL STATEMETNS ARE NOW REQUIRED TO BE ATTACHED TO FORM 990. AUDITED FINANCIAL INFORMATION IS POSTED ANNUALLY ON THE HOPSITAL'S WEBSITE. FORM 990 PART IX LINE 11G DESCRIPTION:EMERGENCY SERVICES TOTAL FEES:1927477 FORM 990 PART IX LINE 11G DESCRIPTION:ANESTHESIA SERVICES TOTAL FEES:221707 FORM 990 PART IX LINE 11G DESCRIPTION:LABORATORY SERVICES TOTAL FEES:489674 FORM 990 PART IX LINE 11G DESCRIPTION:PHARMACY SERVICES TOTAL FEES:24668 FORM 990 PART IX LINE 11G DESCRIPTION:FAMILY MEDICINE SERVICES TOTAL FEES:761457 FORM 990 PART IX LINE 11G DESCRIPTION:OTHER PROFESSIONAL FEES TOTAL FEES:1527505 GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1836 SOUTH AVENUE LA CROSSE WI 54601 391866425 SUPPORT ORG WI 501(C)(3) LINE 12B,II NA false GUNDERSEN LUTHERAN MEDICAL CENTER INC 1910 SOUTH AVENUE LA CROSSE WI 54601 390813416 HEALTHCARE WI 501(C)(3) LINE 3 GLHS false GUNDERSEN CLINIC LTD 1836 SOUTH AVENUE LA CROSSE WI 54601 391028657 HEALTHCARE WI 501(C)(3) LINE 3 GLHS false GUNDERSEN LUTHERAN ADMIN SVS 1910 SOUTH AVE LA CROSSE WI 54601 391606449 SUPPORT ORG WI 501(C)(3) LINE 12B,II GLHS false GUNDERSEN LUTHERAN MEDICAL FOUNDATION 1836 SOUTH AVE LA CROSSE WI 54601 391249705 FOUNDATION WI 501(C)(3) LINE 7 GLHS false GUNDERSEN LUTHERAN CREDENTIALING SVC 1910 SOUTH AVENUE LA CROSSE WI 54601 391856898 CREDENTIALING WI 501(C)(3) LN 12C III GLHS false TRI-COUNTY MEMORIAL HOSPITAL INC 18601 LINCOLN STREET WHITEHALL WI 54773 390704510 HEALTHCARE WI 501(C)(3) LINE 3 GLHS false TRI-COUNTY MEMORIAL FOUNDATION INC 18601 LINCOLN STREET WHITEHALL WI 54773 300093022 FOUNDATION WI 501(C)(3) LINE 7 TCMH false HARMONY COMMUNITY HEALTHCARE INC 815 MAIN AVENUE SOUTH HARMONY MN 55939 410711606 HEALTHCARE MN 501(C)(3) LINE 10 GLHS false TWEETEN LUTHERAN HEALTHCARE CENTER INC 125 FIFTH AVENUE SE SPRING GROVE MN 55974 411565003 HEALTHCARE MN 501(C)(3) LINE 10 GLHS false TRI-STATE AMBULANCE INC 235 CAUSEWAY BLVD LA CROSSE WI 54603 391965415 MDCL TRANSPOR WI 501(C)(3) LINE 3 GLHS false TRI-STATE REGIONAL AMBULANCE INC 235 CAUSEWAY BLVD LA CROSSE WI 54603 391962965 MDCL TRANSPOR WI 5001(C)(3) LINE 10 GLHS false LUTHERAN REAL ESTATE HOLDING CORPORATION 1910 SOUTH AVENUE LA CROSSE WI 54601 391480826 HOUSING WI 501(C)(3) LN 12C, III GLHS false LUTHERAN HOUSING OF LA CROSSE INC 1900 SOUTH AVENUE LA CROSSE WI 54601 391751934 IND. LIVING WI 501(C)(3) LINE 10 LRHC false COMMUNITY HOUSING OF LA CROSSE INC 1900 SOUTH AVENUE LA CROSSE WI 54601 391586700 IND. LIVING WI 501(C)(3) LINE 10 LRHC false ST JOSEPH'S HEALTH SERVICES INC 400 WATER AVENUE HILLSBORO WI 54634 390929538 HEALTHCARE WI 501(C)(3) LINE 3 GLHS false ST JOSEPH'S MEMORIAL FOUNDATION 400 WATER AVENUE HILLSBORO WI 54634 391455787 FOUNDATION WI 501(C)(3) LINE 12A, I S JOSEPH HS false MEMORIAL HOSPITAL OF BOSCOBEL 205 PARKER STREET BOSCOBEL WI 53805 390845590 HEALTHCARE WI 501(C)(3) LINE 3 GLHS false MEMORIAL HOSPITAL OF BOSCOBEL FOUNDATION 205 PARKER STREET BOSCOBEL WI 53805 391688793 FOUNDATION WI 501(C)(3) LINE 7 MHOB false BOSCOBEL AREA HEALTHCARE PARTNERS 205 PARKER STREET BOSCOBEL WI 53805 450498844 FUNDRAISING WI 501(C)(3) LINE 7 NA false PALMER LUTHERAN HEALTH CENTER INC 112 JEFFERSON STREET WEST UNION IA 52175 421320763 HEALTHCARE IA 501(C)(3) LINE 3 GLHS false PALMER MEMORIAL FOUNDATION 112 JEFFERSON STREET WEST UNION IA 52175 421032878 FOUNDATION IA 501(C)(3) LINE 7 PLHC false MEMORIAL HC FDN OF ADAMS COUNTY INC 402 WEST LAKE STREET FRIENDSHIP WI 53934 391775074 FOUNDATION WI 501(C)(3) LINE 12A, I MMHC false SAINT ELIZABETH'S HOSPITAL OF WABASHA 1200 5TH GRANT BOULEVARD WEST WABASHA MN 55981 410693877 HEALTHCARE MN 501(C)(3) LINE 3 GLHS false GUNDERSEN LUTHERAN ENVISION LLC 1836 SOUTH AVENUE LA CROSSE WI 54601 264706546 RENEWABLE ENERGY WI GLHS C CORP 0 0 true false false false false false false false false false false false false true false false false false false false