2018-11-12T15:50:11-06:00 2017-12-31 390758449 WIPFLI LLP 4890 OWEN AYRES COURT SUITE 200 EAU CLAIRE WI 54701 990 2017-01-01 390806828 MEMORIAL HOSPITAL INC MEMO 7157433101 216 SUNSET PLACE NEILLSVILLE WI 54456 RYAN NEVILLE CEO 7157433101 2018-11-12 1 DONNA NELSON CPA P00968978 7158323407 2018-11-05 137.26.200.211 2018-11-12 10:44:15 CS P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 558C6F47C777A73CECB93EB9107DCB0C387663C8 2017 2019-02-21 02:37:17Z RYAN NEVILLE 216 SUNSET PLACE NEILLSVILLE WI 54456 27309245 0 X WWW.MEMORIALMEDCENTER.ORG X 1954 WI MEMORIAL HOSPITAL, INC.'S MISSION IS TO PROVIDE THE COMMUNITIES WE SERVE THE BEST EXPERIENCE IN HEALTH CARE, EDUCATION, AND PREVENTION SUPPORTED BY OUR PILLARS OF PEOPLE, SERVICE, QUALITY AND SAFETY, FINANCE, COMMUNITY, AND GROWTH...ONE PATIENT AT A TIME. MEMORIAL HOSPITAL, INC. PROVIDES SERVICES THROUGH ITS 25-BED CRITICAL ACCESS HOSPITAL, ASSISTED LIVING, AS WELL AS 2 RURAL HEALTH CLINICS LOCATED IN NEILLSVILLE AND GREENWOOD, WISCONSIN. TO FULFILL COMMUNITY NEEDS, MEMORIAL HOSPITAL, INC. FACILITATES EDUCATIONAL SEMINARS AND SUPPORT GROUPS LED BY MEDICAL AND PROFESSIONAL STAFF AT GREATLY REDUCED-RATES; PROVIDES FREE HEALTH SCREENINGS AT GIVEN TIMES THROUGHOUT THE YEAR; STAFF BOOTHS AT COMMUNITY EVENTS; SERVES AS AN EDUCATION SITE FOR STUDENTS IN HIGH SCHOOL, TECHNICAL COLLEGE, AND UNIVERSITIES; AS WELL AS OTHER NEEDS AS DETERMINED. MEMORIAL HOSPITAL, INC. ALSO ADMINISTERS A CHARITY CARE PROGRAM HELPING TO ENSURE AFFORDABLE ACCESS TO HEALTH CARE. 11 6 261 79 371723 -230154 251731 162016 27145561 26775310 21757 10575 348408 361344 27767457 27309245 0 0 0 0 15932749 16616084 0 0 0 11811244 11939984 27743993 28556068 23464 -1246823 15617645 14759827 5853669 6242674 9763976 8517153 X TO PROVIDE THE COMMUNITIES WE SERVE THE BEST EXPERIENCE IN HEALTH CARE, EDUCATION, AND PREVENTION, SUPPORTED BY OUR PILLARS OF PEOPLE, SERVICE, QUALITY AND SAFETY, FINANCE, COMMUNITY, AND GROWTH...ONE PATIENT AT A TIME. 0 0 16232702 21259939 MEMORIAL HOSPITAL, INC. (THE "HOSPITAL"), A 25-BED RURAL HOSPITAL, IS A NONPROFIT, NONSTOCK WISCONSIN CORPORATION PROVIDING SERVICES TO NEILLSVILLE, WISCONSIN, AND THE SURROUNDING COMMUNITIES. HOSPITAL INPATIENT SERVICES IN 2017 INCLUDED 842 ACUTE PATIENT DAYS, 188 OBSERVATIONS PATIENTS, AND 148 SWING BED PATIENT DAYS. EMERGENCY ROOM VISITS TOTALED 2,126, URGENT CARE VISITS TOTALED 2,027, AND SURGERIES AND PROCEDURES TOTALED 882 IN 2017.OTHER HOSPITAL SERVICES PROVIDED IN 2017 INCLUDED BUT WERE NOT LIMITED TO: PRIMARY CARE, ORTHOPEDIC AND GENERAL SURGERY CLINIC AND PROCEDURES, ATHLETIC TRAINING, PAIN MANAGEMENT, PHARMACY, PHYSICAL THERAPY, RADIOLOGY, LABORATORY, CARDIAC REHABILITATION, RESPIRATORY THERAPY, OCCUPATIONAL THERAPY, AND DIABETIC EDUCATION. 6427167 5024428 MEMORIAL HOSPITAL, INC. ALSO OWNS AND OPERATES TWO CLINICS LOCATED IN NEILLSVILLE AND GREENWOOD, WISCONSIN. TOTAL CLINIC VISITS FOR 2017 WERE 21,407. 746891 308662 THE ASSISTED LIVING FACILITY IS AN ALTERNATIVE FOR SENIORS WHO CAN NO LONGER LIVE SAFELY IN THEIR OWN HOME, YET DO NOT NEED 24-HOUR MEDICAL SUPERVISION. SUNSET GARDENS IS A HOUSING AND HEALTH CARE ALTERNATIVE, COMBINING INDEPENDENCE WITH PERSONAL CARE, IN A WARM, DIGNIFIED, HOME-LIKE ATMOSPHERE. SUNSET GARDENS HAS 11 PRIVATE ROOMS AND 2 DOUBLE ROOMS, FOR A COUPLE OR SIBLINGS. MEALS, SNACKS, HOUSEKEEPING, LAUNDRY, CABLE TELEVISION, AND MAINTENANCE SERVICES ARE PROVIDED. SOCIAL AND RECREATIONAL PROGRAMS AND A CHAPEL ARE ALSO PROVIDED. HEALTH CARE SERVICES INCLUDE A REGISTERED NURSE ON-SITE OR ON-CALL 24-HOURS PER DAY, MEDICATION MANAGEMENT, AND PERSONAL CARE SERVICES PROVIDED BY CERTIFIED NURSING ASSISTANTS (SUCH AS ASSISTANCE WITH BATHING, DRESSING, AND GROOMING). THE ASSISTED LIVING PROVIDED APPROXIMATELY 3,531 RESIDENT DAYS DURING 2017. 23406760 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 1 1 0 0 0 1 56 0 261 1 1 1 0 0 0 0 0 0 0 0 0 X 11 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X KELLY SILBERNAGEL 7157433101 216 SUNSET PLACE NEILLSVILLE WI 54456 X RICHARD SZYMANSKI BOARD MEMBER 1.00 X 300 0 0 TREVOR WUETHRICH BOARD MEMBER 1.00 X 225 0 0 MARY KAY MILLS BOARD MEMBER 1.00 0.50 X 275 0 0 JAMES CHADWICK BOARD MEMBER 1.00 X 225 0 0 GARY WEIRAUCH VICE CHAIR 1.00 X X 275 0 0 BARBARA PETKOVSEK BOARD MEMBER 1.00 X 225 0 0 DR MARIA CRUZ-APOLINARIO BOARD MEMBER/PHYSICIAN 32.00 X 520243 0 27478 RUSSELL RATSCH CHAIRMAN 2.00 X X 300 0 0 BRIAN BARTH BOARD MEMBER 1.00 X 125 0 0 KEVIN GRAP SECRETARY 1.00 X X 175 0 0 DR DAVID CARLSON PHYSICIAN 33.00 X 712952 0 24850 ROBERT BARTH BOARD MEMBER 1.00 X 100 0 0 RYAN NEVILLE PRESIDENT & CEO 40.00 0.50 X 300708 0 28721 KELLY SILBERNAGEL CFO 40.00 X 125629 0 18704 DR TIMOTHY MEYER CHIEF MEDICAL OFFICER 33.00 0.50 X 439637 0 13129 DR AMY SCHNEIDER DE CORTEZ PHYSICIAN 32.00 X 264720 0 29178 DR PETER THURLOW PHYSICIAN 32.00 X 357027 0 21424 2723141 0 163484 25 0 1 0 MEDICAL SOLUTIONS LLC 1010 N 102ND ST STE 300 OMAHA NE 68114 AGENCY STAFFING 1055971 HORTY ELVING 332 MINNESOTA ST STE W2000 ST PAUL MN 55101 ARCHITECTURE 833260 EMERGENCY PRACTICE ASSOCIATES INC PO BOX 1260 WATERLOO IA 50704 AGENCY STAFFING 725531 WI ANETHESIA SERVICE LLC W5844 ROLLING HILL DRIVE NEILLSVILLE WI 54456 ANETHESIA SERVICES 481607 MARSHFIELD CLINIC 1000 N OAK AVE MARSHFIELD WI 54449 PROFESSIONAL SERVICES 302329 12 86813 8576 66627 162016 HOSPITAL REVENUE 621110 21270318 21259939 10379 CLINIC REVENUE 621110 5024428 5024428 ASSISTED LIVING REVENUE 623000 308662 308662 171902 171902 26775310 10473 10473 102 0 102 102 102 DIET,MAINT,HSKG,LNDRY 812900 361344 361344 361344 27309245 26593029 371723 182477 X 1761985 1285523 476462 11163296 9227016 1936280 333341 275523 57818 2568367 2118050 450317 789095 643568 145527 20157 20157 5077597 4544799 532798 63553 63553 1009111 797531 211580 556762 556762 445335 303839 141496 72751 55190 17561 1270437 866782 403655 170562 66804 103758 MEDICAL SUPPLIES 1998522 1998522 BAD DEBT 691434 691434 EQUIPMENT RENTAL & MAIN 486423 454839 31584 ADMIN HOSPITAL TAX EXPE 77340 77340 28556068 23406760 5149308 0 143189 93225 3078115 943648 3499372 3791701 634591 638936 142330 287206 19131269 13594806 5421478 5536463 2698570 3468648 15617645 14759827 2854776 2898516 1699113 1656256 1299780 1687902 5853669 6242674 X 9763976 8517153 9763976 8517153 15617645 14759827 -1246823 0 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 6787 6787 0 PART II-B, LINE 1: MEMORIAL HOSPITAL, INC. 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 MEMORIAL HOSPITAL, INC. THAT $2,687 OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTH CARE ENVIRONMENT. MEMORIAL HOSPITAL, INC. IS ALSO A MEMBER OF THE RURAL WISCONSIN HEALTH COOPERATIVE (RWHC). EACH YEAR, MEMORIAL HOSPITAL, INC. PAYS MEMBERSHIP FEES TO THE 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 FINDING GRANT FUNDING FOR NEW PROGRAMS, LEGAL SERVICES, REIMBURSEMENT REVIEW SERVICES, ACCOUNTING ASSISTANCE, CONTRACTING FOR THERAPIST AND EMERGENCY ROOM PHYSICIAN COVERAGE, AND ADMINISTRATIVE CONSULTING SERVICES. AS A PART OF THESE SERVICES, THE RWHC ALSO DOES PROVIDE ANALYSIS ON CURRENT HEALTH CARE ISSUES IN AN EFFORT TO PROMOTE BETTER HEALTH CARE FOR HOSPITALS IN RURAL COMMUNITIES THROUGHOUT WISCONSIN. ONE OF THESE EFFORTS ALSO INCLUDES SOME LOBBYING ON THE PART OF THE MEMBER ORGANIZATIONS. THE RWHC DETERMINED THAT $4,100 OF THE FEES PAID IN 2017 RELATED TO LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE HEALTH CARE ENVIRONMENT IN THE STATE OF WISCONSIN. 15713 15713 10902056 7723377 3178679 6729439 5622481 1106958 1484061 248948 1235113 5536463 INVESTMENT IN CENTRAL MN DIAGNOSTIC, INC. 420245 DEFERRED COMPENSATION PLAN ASSETS 1701864 AMOUNTS RECEIVABLE FROM THIRD-PARTY REIMBURSEMENT PROGRAMS 1100000 OTHER RECEIVABLES 246539 3468648 DEFERRED COMPENSATION LIABILITIES 1687902 1687902 1 1 1 X 1 X 1 1 0 1 1 177779 177779 0.00620 3871621 2185329 1686292 0.05910 4049400 2185329 1864071 0.06530 32083 2086 29997 0.00110 110970 110970 0.00390 10135311 5190793 4944518 0.17320 2342 2342 0.00010 6736 6736 0.00020 10287442 5192879 5094563 0.17850 14336842 7378208 6958634 0.24380 3435 3435 0.00010 56699 56699 0.00200 131 131 0.00000 60265 60265 0.00210 0 426338 170535 2878086 2892836 -14750 X 1 1 1 1 MEMORIAL HOSPITAL INC 216 SUNSET PLACE NEILLSVILLE WI 54456 WWW.MEMORIALMEDCENTER.ORG 1026 X X X X MEMORIAL HOSPITAL INC 1 0 0 1 X X X X X X X X X X 16 1 1 1 1 X WWW.MEMORIALMEDCENTER.ORG X 1 16 1 WWW.MEMORIALMEDCENTER.ORG 0 1 X 100.000000000000 300.000000000000 X X X 1 1 X X X X 1 X WWW.MEMORIALMEDCENTER.ORG X HTTP://MEMORIALMEDCENTER.ORG/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE/ X HTTP://MEMORIALMEDCENTER.ORG/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE/ X X X X X 1 X 0 X X X 1 X 0 0 MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 3J: MEASUREABLE GOALS RELATED TO TOP IDENTIFIED NEEDS OF THE COMMUNITY. MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 5: REPRESENTATIVES FROM MEMORIAL HOSPITAL, INC. AND 23 OTHER ORGANIZATIONS FORMED A GROUP CALLED THE HEALTHY CLARK COUNTY COALITION (HCCC) SINCE THE LAST HEALTH NEEDS ASSESSMENT. THIS GROUP HAS REPRESENTATIVES FROM SCHOOLS, FAITH-BASED ORGANIZATIONS, WORKSITES, LOCAL HOSPITALS/HEALTH CARE SYSTEMS, AND OTHER COMMUNITY-BASED ORGANIZATIONS WHICH SET THEIR WORKFLOW FOR IDENTIFYING HEALTH FOCUS AREAS. AS A GROUP, HCCC REVIEWED DATA AND SET THE COUNTY'S GOALS AND INITIATIVES THROUGH THE YEAR 2020. MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 6A: THE CHNA WAS CONDUCTED IN JOINT EFFORT WITH MINISTRY OUR LADY OF VICTORY HOSPITAL (STANLEY, WISCONSIN). THERE WERE ALSO OTHER HEALTHCARE PROVIDERS INVOLVED INCLUDING FAMILY HEALTH CENTER OF MARSHFIELD-NEILLSVILLE DENTAL CLINIC, MIDWIFERY PRACTICES AND A LOCAL PRIVATE DENTAL CLINIC. MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 6B: THE CHNA WAS CONDUCTED IN JOINT EFFORT WITH THE CLARK COUNTY PUBLIC HEALTH DEPARTMENT AS WELL AS 22 OTHER ORGANIZATIONS INCLUDING SCHOOLS, FAITH-BASED ORGANIZATIONS, WORKSITES, AND OTHER COMMUNITY BASED ORGANIZATIONS. MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 11: THROUGH ITS COMMUNITY NEEDS ASSESSMENT, THE HEALTHY CLARK COUNTY COALITION (HCCC), IDENTIFIED THREE AREAS TO FOCUS ON THROUGH THE YEAR 2020 WITH INIATIVES AND MEASURABLE GOALS. MEMORIAL HOSPITAL, INC. IS PARTICIPATING IN COMMUNITY WORK AND IMPLEMENTING ITS OWN STRATEGIES TOWARDS THE SUCCESS OF HCCC MEETING ITS GOALS. THE FOLLOWING ARE THE FOCUS AREAS IDENTIFIED: A) ADEQUATE, APPROPRIATE AND SAFE FOOD AND NUTRITIONB) MENTAL HEALTHC) ALCOHOL AND OTHER DRUG ABUSE FOLLOWING ARE KEY INIATIVES THE HOSPITAL HAS BEEN DIRECTLY INVOLVED IN SINCE THE ASSESSMENT WAS CONDUCTED IN 2016:1) HELD COMMUNITY PRESENTATIONS ON NUTRITION AT HOSPITAL AND LOCAL BUSINESSES HOSTED BY THE DIETICIAN2) MEDICAL STAFF WORKING ON A WEIGHT LOSS PROGRAM3) PROVIDES AN INCENTIVISED WELLNESS PROGRAM TO EMPLOYEES4) PARTICIPATED IN CLARK CO. EMERGENCY MENTAL HEALTH INTERVENTION5) ACTIVELY ATTENDED AND SUPPORTED THE COUNTY MENTAL HEALTH TASK FORCE6) PRESENTED ON WELLNESS TOPICS AT LOCAL BUSINESS7) STAFF PARTICIPATED IN "EAT RIGHT BE FIT" COALITIN IN COUNTY8) STUDIED RURAL MENTAL HEATLH CARE DELIVERY MODELS AND IS RECRUITING TO PROVIDE LOCAL SERVICES9) PROVIDES HEALTH CARE TO INCARCERATED INDIVIDUALS10) HIRED PEDIATRICIAN TO BETTER SERVE CHILDREN'S NEEDS MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 16J: INFORMATION IS PROVIDED AT REGISTRATION AND NOTES ABOUT FINANCIAL ASSISTANCE ARE ADDED TO PATIENT BILLS, OF WHICH AT LEAST THREE ARE SENT. IF A BALANCE STILL EXISTS AFTER THREE STATEMENTS A COPY OF THE PLAIN LANGUAGE SUMMARY IS SENT WITH A FINAL NOTICE. THE HOSPITAL EMPLOYS DEDICATED STAFF TO DISCUSS OPTIONS AVAILABLE FOR THE PATIENT. 3 1 - MEMORIAL MEDICAL CENTER 216 SUNSET PLACE NEILLSVILLE WI 54456 PROVIDER-BASED RURAL HEALTH CLINIC 2 - GREENWOOD FAMILY MEDICAL CENTER 201 SOUTH MAIN GREENWOOD WI 54437 PROVIDER-BASED RURAL HEALTH CLINIC 3 - SUNSET GARDENS 216 SUNSET PLACE NEILLSVILLE WI 54456 ASSISTED LIVING FACILITY PART I, LINE 6A: MEMORIAL 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 THE WHA'S WEBSITE. PART I, LINE 7: THE COSTING METHOD 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 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: THE COST OF SUBSIDIZED HEALTH SERVICES IS BASED ON COST ALLOCATIONS FROM THE MEDICARE COST REPORT. ALLOWABLE COSTS ARE ASSIGNED DIRECTLY TO DEPARTMENTS THROUGHOUT THE YEAR AND THEN THE COST REPORT USES THE ALLOCATION METHODOLOGY TO ASSIGN ALL OTHER COSTS TO CALCULATE SERVICE LINE COSTS. SUBSIDIZED HEALTH SERVICES INCLUDE THE OPERATION OF TWO FAMILY PRACTICE CLINICS, HOSPITAL INPATIENT UNIT, EMERGENCY ROOM, AND OTHER HOSPITAL ANCILLARY OUTPATIENT SERVICES. IT IS THE GOAL OF MEMORIAL HOSPITAL, INC. TO PROVIDE THESE SERVICES TO THE COMMUNITY REGARDLESS OF A PATIENT'S ABILITY TO PAY. PART II, COMMUNITY BUILDING ACTIVITIES: COMMUNITY BUILDING ACTIVITIES PROMOTE THE HEALTH OF THE COMMUNITY THAT THE HOSPITAL SERVES. THROUGH COLLABORATION WITH LOCAL ORGANIZATIONS, THE HOSPITAL PROVIDES INFORMATION TO THE COMMUNITY REGARDING VARIOUS ISSUES THAT AFFECT HEALTH SUCH AS BABYSITTING CLASSES, SERVING ON PUBLIC HEALTH BOARDS, WORKING WITH DISASTER PREPAREDNESS, CPR CLASSES, DIABETIC SUPPORT GROUPS, PRESCRIPTION ASSISTANCE, STRESS MANAGEMENT, PREVENTATIVE SERVICES, AND OTHERS. 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 ASSISTANCE WITH THE APPLICATIONS. DUE TO NO RESPONSES FROM SOME PATIENTS, A SIGNIFICANT AMOUNT OF BAD DEBTS COULD BE CONSIDERED AS CHARITY CARE. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE AND CREDIT POLICY: IN EVALUATING THE COLLECTIBILITY OF PATIENT AND RESIDENTS 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 DOUBTFUL 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 PAYOR 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 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 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 INCLUDE A SEPARATE FOOTNOTE REGARDING BAD DEBT EXPENSE. PART III, LINE 8: MEMORIAL HOSPITAL, INC. IS DESIGNATED A CRITICAL ACCESS HOSPITAL AND AS SUCH A PORTION OF ITS REVENUES ARE PAID UNDER A COST REIMBURSEMENT SYSTEM. BASED ON THE INSTRUCTIONS, THE TOTAL MEDICARE REVENUE SHOWN ON THIS FORM 990 INCLUDES ONLY A PORTION OF THE GROSS MEDICARE REVENUE THAT IS ACTUALLY RECEIVED BY THE HOSPITAL FROM THE MEDICARE PROGRAM. THE AMOUNTS LISTED FOR MEDICARE DO NOT INCLUDE PHYSICIAN AND MID-LEVEL PRACTITIONER SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT OR ANESTHESIA SERVICES AT THE HOSPITAL. PHYSICIAN COVERAGE IS REIMBURSED PRIMARILY ON A FEE SCHEDULE REIMBURSEMENT METHODOLOGY AT RATES THAT ARE OFTEN BELOW THE COST OF PROVIDING CARE TO PATIENTS. EMERGENCY AND ANESTHESIA SERVICES PROVIDED TO MEDICARE PATIENTS ARE VITAL TO THE WELL-BEING OF THE COMMUNITY AND THEREFORE THESE COSTS AND SHORTFALLS SHOULD ALSO BE CONSIDERED AS AN ADDITIONAL BENEFIT THAT THE HOSPITAL PROVIDES TO THE COMMUNITY AND SURROUNDING AREA OF NEILLSVILLE, WISCONSIN. THE COSTING METHOD USED ABOVE FOR IRS 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. THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES WHICH ARE REIMBURSED ON A COST METHODOLOGY EXCLUDING THE FEE SCHEDULE ITEMS LIKE PHYSICIAN AND MID-LEVEL PRACTITIONER SERVICES WHICH THE HOSPITAL WOULD SHOW A LARGE LOSS ON THESE SERVICES.WHETHER THERE IS A SHORTFALL OR SURPLUS FROM SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THE RECIPIENTS ARE TYPICALLY ELDERLY AND/OR DISABLED MEMBERS OF THE COMMUNITY AND 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: UNDER THE HOSPITAL'S CHARITY CARE POLICY, MEMORIAL HOSPITAL, INC., MAKES EVERY ATTEMPT TO IDENTIFY AND PROMOTE CHARITY CARE TO PATIENTS. INCLUDED IN THE HOSPITAL'S POLICY IT IS NOTED THAT PATIENTS MAY QUALIFY FOR CHARITY CARE EITHER PRIOR TO ADMISSION OR FOLLOWING DISCHARGE. UNINSURED PATIENTS ARE GIVEN THE OPPORTUNITY TO FILL OUT A CHARITY CARE APPLICATION AT THE TIME OF ADMISSION AND ALL PATIENTS ARE ASKED TO FILL OUT A CHARITY CARE APPLICATION DURING THE COLLECTION PROCESS PRIOR TO SENDING ANY ACCOUNTS TO A COLLECTION AGENCY. IF THE PAPERWORK IS NOT RECEIVED, THE ACCOUNT IS HANDLED THROUGH THE NORMAL COLLECTION PROCESS. PART VI, LINE 2: OUTSIDE OF THE CHNA, THE HOSPITAL CONTINUES TO LOOK AT WAYS IT CAN EXPAND ACCESS TO AFFORDABLE, LOCAL HEALTH CARE AS WELL AS SUPPORT OTHER COMMUNITY ACTIVITIES RELATED TO THE WELLNESS OF CLARK COUNTY. IN 2017 EFFORTS WERE MADE TO EXPAND ACCESS TO LOCAL SPECIALTY CARE ADDING SERVICES OF A PEDIATRICIAN AND INCREASING ONCOLOGY SERVICES LOCALLY, AS WELL AS MAINTAINING OTHER SERVICES. OTHER EFFORTS INCLUDED BEING AN ACTIVE MEMBER IN COUNTY HEALTHCARE INITIATIVES SUCH AS EAT RIGHT BE FIT COALITION AND INCREASING PREVENTATIVE CARE FOR EMPLOYEES BY PROVIDING MORE ONSITE SERVICES TO LOCAL BUSINESSES. PART VI, LINE 3: FINANCIAL ASSISTANCE INFO IS ADDED TO PATIENT BILLS, INFORMATION IS PROVIDED AT REGISTRATION, LETTERS ARE SENT TO PATIENTS WITH NO LISTED INSURANCE AS WELL AS PATIENTS IDENTIFIED AS STRUGGLING WITH PAYING THEIR BILLS, AND OTHER COMMUNITY POSTINGS ARE WAYS MEMORIAL HOSPITAL, INC. WORKS TO NOTIFY PATIENTS OF OUR FINANCIAL ASSISTANCE PROGRAM. PART VI, LINE 4: THE HOSPITAL FOCUSES ON SERVING THE HEALTH NEEDS OF CLARK COUNTY WHICH HAS A POPULATION OF 35,000. THE HOSPITAL SERVES IN A COMMUNITY WHICH RANK'S THIRD LOWEST IN THE STATE OF WISCONSIN FOR PER CAPITA MONEY INCOME INCLUDING 22% OF CHILDREN LIVING IN POVERTY. APPROXIMATELY 30% OF THE COUNTY'S POPULATION IS AMISH/MENNONITE. ROUGHLY 92% OF THE POPULATION LIVES IN A RURAL AREA COMPARED TO THE STATE'S AVERAGE OF 30% WHICH IS SIGNIFICANT DUE TO CLARK COUNTY'S TRANSPORTATION SYSTEM BEING UNDERDEVELOPED. PART VI, LINE 5: WHILE THERE IS A GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFIT HOSPITAL'S COMMUNITY BENEFIT, THIS IS A WORK IN PROGRESS. OUR HOSPITAL PROVIDED FINANCIAL ASSISTANCE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS. WE ALSO OFFER CRITICALLY IMPORTANT COMMUNITY BENEFITS WHICH ARE NOT QUANTIFIED. OUR HOSPITAL, LIKE MOST RURAL HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY. BEYOND INPATIENT HOSPITALIZATIONS, WE PROVIDE LOCAL ACCESS TO MANY HEALTH SERVICES; LAB, RADIOLOGY, EMERGENCY AND URGENT CARE, INFUSION SERVICES, OCCUPATIONAL HEALTH, REHABILITATION SERVICES, SPECIALTY MEDICINE, SLEEP CENTER, SURGICAL AND WOMEN'S HEALTH SERVICES IN A COMMUNITY THAT LACKS ADEQUATE TRANSPORTAION TO TRAVEL TO ANOTHER COMMUNITY. PART VI, LINE 7, REPORTS FILED WITH STATES WI X X X X 0 1 0 1 0 0 0 0 0 DR MARIA CRUZ-APOLINARIO BOARD MEMBER/PHYSICIAN 202235 0 302274 0 15734 0 4500 0 22978 0 547721 0 0 0 DR DAVID CARLSON PHYSICIAN 543547 0 168110 0 1295 0 4500 0 20350 0 737802 0 0 0 RYAN NEVILLE PRESIDENT & CEO 247379 0 25000 0 28329 0 4500 0 24221 0 329429 0 0 0 DR TIMOTHY MEYER CHIEF MEDICAL OFFICER 263362 0 160541 0 15734 0 4500 0 8629 0 452766 0 0 0 DR AMY SCHNEIDER DE CORTEZ PHYSICIAN 165152 0 99476 0 92 0 4500 0 24678 0 293898 0 0 0 DR PETER THURLOW PHYSICIAN 268496 0 87775 0 756 0 0 0 21424 0 378451 0 0 0 PART I, LINE 4B MEMORIAL HOSPITAL, INC. OFFERS AN EXECUTIVE 457(F) RETIREMENT PLAN, ESTABLISHED IN 2006, IN WHICH THE EMPLOYER MAY MAKE DISCRETIONARY CREDITS TO THE DEFERRED COMPENSATION ACCOUNT OF THE PARTICIPANTS. THE AMOUNT CONTRIBUTED TO THE PARTICIPANTS IS DETERMINED ON AN ANNUAL BASIS BY THE EMPLOYER. PART I, LINE 5 DURING 2017, THE FOLLOWING PHYSICIANS RECEIVED COMPENSATION THAT WAS PARTLY BASED ON THE GROSS CHARGES RECOGNIZED FOR THEIR PROFESSIONAL SERVICES: DR. TIMOTHY MEYER $160,541; DR. MARIA CRUZ-APOLINARIO $302,274; DR. DAVID CARLSON $168,110; DR. AMY SCHNEIDER DE CORTEZ $99,476; AND DR. PETER THURLOW $87,775. MARY TORNEHL DAUGHTER OF RUSSELL RATSCH, BOARD CHAIRMAN 25688 EMPLOYMENT COMPENSATION FOR PHYSICIAN SERVICES 0 JAMIE BARTH SISTER-IN-LAW OF BRIAN BARTH, BOARD MEMBER 28339 EMPLOYMENT COMPENSATION FOR RESPIRATORY THERAPY 0 THOMAS SILBERNAGEL FAMILY MEMBER OF OFFICER, KELLY SILBERNAGEL 481607 OWNER OF COMPANY PROVIDING 24/7 CRNA COVERAGE 0 LINDA ORMOND SISTER OF BOARD MEMBER, BARBARA PETKOVSEK 38783 EMPLOYMENT COMPENSATION FOR PATIENT BENEFIT SPECIALIST 0 JENNIFER LARSON DAUGHTER OF DR. DAVID CARLSON, HIGHEST COMPENSATED EMPLOYEE 46655 EMPLOYMENT COMPENSATION FOR PHYSICIAN ASSISTANT SERVICES 0 KEVIN GRAP OFFICER OF COMPANY, KEVIN GRAP 30682 RADIO ADVERTISING 0 FORM 990, PART VI, SECTION B, LINE 11B THE CHIEF FINANCIAL OFFICER DETAIL REVIEWS THE FORM 990 PRIOR TO SUBMISSION. ALSO, BEFORE THE RETURN WAS FILED, A DRAFT COPY WAS MADE AVAILABLE TO THE BOARD OF DIRECTORS FOR REVIEW AND COMMENTS. FORM 990, PART VI, SECTION B, LINE 12C MEMORIAL HOSPITAL, INC. RELIES ON THE ANNUAL DISCLOSURE OF KEY INDIVIDUALS TO THE BOARD OF DIRECTORS AND MONITORS PURCHASES AND ABSTENTIONS FROM NECESSARY VOTES THROUGHOUT THE YEAR. ALL MANAGERS AND MEDICAL STAFF ARE REQUIRED TO DISCLOSE AND FOLLOW THE CONFLICT OF INTEREST POLICY. FORM 990, PART VI, SECTION B, LINE 15 A COMMITTEE OF THE BOARD OF DIRECTORS HAS BEEN DESIGNATED TO REVIEW THE CHIEF EXECUTIVE OFFICER'S (CEO) AND CHIEF FINANCIAL OFFICER'S (CFO) PAY. THE REST OF EXECUTIVES AND HIGHLY COMPENSATION INDIVIDUALS ARE REVIEWED BY THE CEO, CFO, AND EXECUTIVE DIRECTOR STAFF EXPERIENCE. MARKET DATA IS PROVIDED TO THE COMMITTEE IN THEIR EVALUATION OF PAY CHANGES. COMPARABILITY DATA WAS USED AND THE RESULTS OF ANY EXECUTIVE PAY CHANGES WERE DOCUMENTED. NO ONE WITH A CONFLICT OF INTEREST WAS INCLUDED IN THE DECISION MAKING OF EXECUTIVE COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 ALL DOCUMENTS ARE AVAILABLE UPON REQUEST. DOCUMENTS ARE ALSO DISCUSSED AT COMMUNITY MEETINGS AND EMPLOYEE FORUMS. FORM 990, PART VII, LINE 1A, EXPLANATION FOR HOURS WORKED: SOME OFFICERS AND BOARD MEMBERS ALSO PROVIDED SERVICE TO COUNTRY VIEW, INC., A RELATED ORGANIZATION. THESE HOURS ARE REFLECTED IN LINE 2 OF COLUMN B. FORM 990, PART IX, LINE 11G CONTRACTED LABORATORY SERVICES: PROGRAM SERVICE EXPENSES 166,679. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 166,679. CONTRACTED EMERGENCY ROOM PHYSICIANS: PROGRAM SERVICE EXPENSES 1,130,176. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,130,176. CONTRACTED ANESTHESIA SERVICES: PROGRAM SERVICE EXPENSES 505,515. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 505,515. CONTRACTED RADIOLOGY SERVICES: PROGRAM SERVICE EXPENSES 754,797. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 754,797. OTHER CONTRACTED SERVICES: PROGRAM SERVICE EXPENSES 690,697. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 690,697. CONTRACTED ADMINISTRATIVE SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 532,798. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 532,798. CONTRACTED NURSING SERVICES: PROGRAM SERVICE EXPENSES 1,296,935. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,296,935. FORM 990, PART XII, LINE 2C: THE BOARD OF DIRECTORS IS RESPONSIBLE FOR THE SELECTION OF AN INDEPENDENT AUDITOR AND MANAGEMENT OVERSEES THE AUDIT PROCESS. THIS PROCESS DID NOT CHANGE IN 2017. COUNTRY VIEW INC 216 SUNSET PLACE NEILLSVILLE WI 54456 391411586 ELDERLY HOUSING WI 501(C)(3) LINE 9 MEMORIAL HOSPITAL INC 1 THE FOUNDATION OF MEMORIAL HOSPITAL INC 216 SUNSET PLACE NEILLSVILLE WI 54456 383800811 FUNDRAISING WI 501(C)(3) LINE 7 MEMORIAL HOSPITAL INC 1 0 0 1 0 0 0 0 0 0 0 0 1 0 0 1 0 1 0 0 THE FOUNDATION OF MEMORIAL HOSPITAL INC C 86813 COST