2017-11-15T06:49:29-06:00 2016-12-31 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2016-01-01 581734026 UPSON COUNTY HOSPITAL INC UPSO 7066478111 801 WEST GORDON STREET THOMASTON GA 302860027 JOHN WILLIAMS CFO 7066478111 2017-11-15 1 Amy Bibby P00445891 8282542254 12.25.12.224 2017-11-15 06:43:29 ES P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 ADBFC64F84809A3D359AE279AE52D225AAF16287 2016 2017-02-10 21:41:12Z UPSON REGIONAL MEDICAL CENTER TRIPP PENN 801 WEST GORDON STREET THOMASTON GA 302860027 99927963 0 X WWW.URMC.ORG X 1951 GA UPSON REGIONAL MEDICAL CENTER'S MISSION IS TO PROVIDE QUALITY HEALTH CARE SERVICES TO THE SURROUNDING AREA, REGARDLESS OF THE ABILITY TO PAY. 9 9 775 76 541011 -25166 152500 93381 88863878 94883687 5061824 4090379 1169123 860516 95247325 99927963 29269 40993 0 0 36896588 39198309 0 0 0 51301117 56070666 88226974 95309968 7020351 4617995 171718218 174851593 26689247 23307987 145028971 151543606 UPSON REGIONAL MEDICAL CENTER'S MISSION IS TO PROVIDE QUALITY HEALTH CARE SERVICES TO THE SURROUNDING AREA, REGARDLESS OF THE ABILITY TO PAY. 0 0 73291192 40993 94883687 UPSON REGIONAL MEDICAL CENTER OFFERS A COMPLETE LINE OF MEDICAL SERVICES INCLUDING 24-HOUR EMERGENCY CENTER, MEDICAL-SURGICAL CARE, OBSTETRICS, PEDIATRICS, WOMEN'S HEALTH SERVICES, AND MORE. PATIENT DAYS FOR THE YEAR TOTALED 12,458 IN 2016. 73291192 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 1 0 0 0 0 0 1 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 149 0 1 775 1 1 1 1 CJ 0 0 0 0 0 0 0 0 X 9 9 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 0 GA X JOHN WILLIAMS CFO 7066478111 801 WEST GORDON ST THOMASTON GA 302860227 William Hightower CHAIRMAN 0.75 0.15 X X 0 0 0 James J Edwards VICE CHAIRMAN/VICE PRESIDE 0.75 0.15 X X 0 0 0 Barney Hancock SECRETARY/TREASURER 0.75 0.15 X X 0 0 0 Dr Ralph Warnock ASSISTANT SECRETARY 0.75 0.15 X 0 0 0 Kay Robinson BOARD MEMBER 0.75 0.15 X 0 0 0 Steve Keadle BOARD MEMBER 0.75 0.15 X 0 0 0 Kay Searcy BOARD MEMBER 0.75 0.15 X 0 0 0 Scott Blackstock BOARD MEMBER 0.75 0.15 X 0 0 0 Dr JonAthan Busbee BOARD MEMBER 0.75 0.15 X 0 0 0 TRIPP PENN CEO (FROM JUNE) 40.00 1.00 X 201568 0 22470 John Williams CFO 40.00 1.00 X 219701 0 18664 MARK HARTMAN INTERIM CEO (THRU MAY) 40.00 X 0 0 0 Dr Brandon M Boyce Orthopedic Surgeon 40.00 X 1206499 0 39397 DR NANCY BUTLER ENT SURGEON 40.00 X 488247 0 13992 Dr Robert Solyomvari Surgeon 40.00 X 602644 0 39337 DR DARRYL KNIGHT SUrgeon 40.00 X 490266 0 39397 Dr Daniel A Bridges Surgeon 40.00 X 545692 0 44505 3754617 0 217762 40 0 1 0 Navin Haffy & Associates LLC 1900 West Park Drive Suite 180 Westborough MA 01581 Consultants 1542261 Medical Information Technology Inc One Medi Tech Circle Westwood MA 02090 Operating System Vendor 1363522 Innovative Therapy Concepts LLC 2 Mashburn Street Suite 102 Hawkinsville GA 31036 Physical Therapy Contractor 1206944 Pelicano Construction 415 Pine Avenue Suite 200 Albany GA 31701 Construction Contractor 1076178 Sodexo Inc & Affiliates PO Box 536922 Atlanta GA 30353 Food Service Contractor 1014372 37 87999 5382 93381 Gross Patient Service Revenue 621990 94107981 94107981 EHR Incentives 621990 775706 775706 94883687 2913865 2913865 109000 0 109000 109000 109000 1176514 0 1176514 1176514 1176514 Wellness Center 713940 585411 520105 65306 Miscellaneous 561499 145199 145199 OUTSIDE CATERING 722320 20906 20906 751516 99927963 94883687 541011 4409884 X 40993 40993 421269 421269 30728262 22479733 8248529 457175 329930 127245 5464308 3943436 1520872 2127295 1535208 592087 422083 38400 383683 439856 439856 279433 279433 11795910 6320171 5475739 131284 95 131189 4355908 1675520 2680388 1042544 198018 844526 1683606 1683606 190664 80987 109677 546741 546741 6077546 6077546 412972 412972 Bad Debt Expense 19831752 19831752 Medical Supplies 8266244 8266244 Miscellaneous 262171 44629 217542 OTHER EXPENSE 203881 203881 128071 128071 95309968 73291192 22018776 0 5249 5451 15407779 5228384 12622773 12793209 1764369 1911992 959821 1195936 120880389 65601880 48672983 55278509 92047245 98349330 237999 88782 171718218 174851593 5751022 5305931 8790000 7928947 12148225 10073109 26689247 23307987 X 145028971 151543606 145028971 151543606 171718218 174851593 4617995 1896640 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 10456 10456 0 Part II-B, Line 1: THE ORGANIZATION PAYS ANNUAL DUES TO NATIONAL AND STATE INDUSTRY ORGANIZATIONS. A PORTION OF THOSE DUES ARE ATTRIBUTABLE TO THE LOBBYING ACTIVITIES OF THESE ORGANIZATIONS FOR THE BENEFIT OF THEIR MEMBERS. 1922815 1922815 62887832 30988718 31899114 972556 720616 251940 47390256 33892546 13497710 7706930 7706930 55278509 EST THIRD PARTY PAYOR SETTLEMENTS 554025 CAPITAL LEASE OBLIGATION 8037408 CAP RESERVES 1481676 10073109 X Part X, Line 2: The Hospital and Foundation are not-for-profit corporations and are tax-exempt pursuant to Section 501(c)(3) of the Internal Revenue Code. The Segregated Portfolio intends to conduct its affairs in a manner in which it will not be subject to U.S. federal income tax or Georgia income tax. The remaining wholly owned subsidiaries are considered disregarded entities and are included in the Hospital's tax filings. Therefore, no provision for federal income taxes has been made in the accompanying financial statements. The Hospital and Foundation apply accounting policies that prescribe when to recognize and how to measure the financial statement effects of income tax positions taken or expected to be taken on its income tax returns. These rules require management to evaluate the likelihood that, upon examination by the relevant taxing jurisdictions, those income tax positions would be sustained. Based on that evaluation, the Hospital and Foundation only recognize the maximum benefit of each income tax position that is more than 50% likely of being sustained. To the extent that all or a portion of the benefits of an income tax position are not recognized, a liability would be recognized for the unrecognized benefits, along with any interest and penalties that would result from disallowance of the position. Should any such penalties and interest be incurred, they would be recognized as operating expenses. Based on the results of management's evaluation, no liability is recognized in the accompanying balance sheet for unrecognized income tax positions. Further, no interest or penalties have been accrued or charged to expense as of December 31, 2016 and 2015 or for the years then ended. The Hospital and Foundation's tax returns are subject to possible examination by the taxing authorities. For federal income tax purposes, the tax returns essentially remain open for possible examination for a period of three years after the respective filing deadlines of those returns. CENTRAL AMERICA & THE CARIBBEAN 1 1 CAPTIVE INSURANCE 3033001 1 1 0 0 1 1 3033001 0 3033001 0 0 1 0 0 0 1 1 X 1 X 125.000000000000 1 X 1 1 1 0 1 1 3915826 721996 3193830 0.04230 14159584 9448090 4711494 0.06240 18075410 10170086 7905324 0.10470 7231 7231 0.00010 7542647 5518514 2024133 0.02680 10241 10241 0.00010 7560119 5518514 2041605 0.02700 25635529 15688600 9946929 0.13170 11500 11500 0.00020 206050 206050 0.00270 217550 217550 0.00290 1 19831752 0 15655126 21789463 -6134337 X 1 1 1 1 UPSON COUNTRY HOSPITAL 801 WEST GORDON STREET THOMASTON GA 30286 http://www.urmc.org/ 145-415 X X X UPSON COUNTY HOSPITAL INC 1 0 0 1 X X X X X X X X 15 1 0 0 1 X http://www.urmc.org/content_pages/84 1 15 1 http://www.urmc.org/content_pages/84 0 1 X 125.000000000000 300.000000000000 1 1 X X X X X 1 X http://www.urmc.org/documents?doc_type=patient_documents X http://www.urmc.org/documents?doc_type=patient_documents X http://www.urmc.org/documents?doc_type=patient_documents X X X X X 1 X 0 X X X X X 1 X 0 0 UPSON COUNTY HOSPITAL INC Part V, Section B, Line 5: Upson selected a geographic service area definition. This definition was based upon the Hospital's primary service area in a manner that included the broad interests of the community served and included medically underserved populations, low-income persons, minority groups, or those with chronic disease needs. Upson County was selected as the community for inclusion in the CHNA. Upson identified community leaders, partners, and representatives to include in the CHNA process. Individuals, agencies, partners, potential partners, and others were requested to work with the hospital to 1) assess the needs of the community, 2) review available community resources and 3) prioritize the health needs of the community. Groups or individuals, who represent medically-underserved populations, low income populations, minority populations, and populations with chronic diseases were included. Community stakeholders (also called key informants) are people invested or interested in the work of the hospital, people who have special knowledge of health issues, people important to the success of any hospital Community Health Needs Assessment or health project, or are formal or informal community leaders. The hospital identified 10 community members to participate in the stakeholder interviews. UPSON COUNTY HOSPITAL INC Part V, Section B, Line 11: Information gathered from community-wide surveys, stakeholder interviews, discussions with the hospital leadership team, review of demographic and health status data, and hospital utilization data was used to determine the priority health needs of the population.URMC provided a written report of the observations, comments, and priorities resulting from the stakeholder interviews. The Leadership team reviewed this information, focusing on the identified needs, priorities, and current community resources available. Leadership debated the merits and values of these priorities, and considered the resources available to meet these needs. From this information and discussions, the hospital developed the priority needs of the community, each of which are addressed separately in the Hospital's Implementation Strategy document. UPSON COUNTY HOSPITAL INC Part V, Section B, Line 15e: Information is mailed to all patients on summary bills and each statement as long as a balance is outstanding. It is available on the hospital website and any entrance point of the hospital. UPSON COUNTY HOSPITAL INC Part V, Section B, Line 20e: ECA will not begin until after 240 days. 6 1 - UPSON MEDICAL ASSOCIATES LLC 801 W GORDON STREET THOMASTON GA 30286 PHYSICIANS OFFICE 2 - UPSON REGIONAL WELLNESS CENTER LLC 801 W GORDON STREET THOMASTON GA 30286 WELLNESS CENTER 3 - ORTHOPEDICS SPORTS MEDICINE AND SURGERY 801 W GORDON STREET THOMASTON GA 30286 PHYSICIANS OFFICE 4 - UPSON WOMEN'S SERVICES LLC 801 W GORDON STREET THOMASTON GA 30286 PHYSICIANS OFFICE 5 - UPSON FAMILY PHYSICIANS LLC 801 W GORDON STREET THOMASTON GA 30286 PHYSICIANS OFFICE 6 - UPSON SURGICAL ASSOCIATES LLC 801 W GORDON STREET THOMASTON GA 30286 PHYSICIANS OFFICE Part I, Line 7g: SUBSIDIZED HEALTH SERVICES COSTS INCLUDE THOSE ATTRIBUTABLE TO UPSON MEDICAL ASSOCIATES, UPSON WOMEN'S SERVICES, UPSON SURGICAL ASSOCIATES, ORTHOPEDIC SPORTS MEDICINE, AND UPSON FAMILY PHYSICIANS. THESE CLINICS PROMOTE HEALTH CARE FOR UNDESERVED POPULATIONS IN THE AREA. Part I, Line 7, Column (f): The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 19,831,752. Part II, Community Building Activities: Health professionals recruitment and Staff member appointed by city Mayor to represent Thomaston and healthcare workforce needs on the Three Rivers Workforce Investment Board for Region 4. Part III, Line 2: The Bad Debt expense amount above represent the amount of charges considered uncollectible after reasonable attempts to collect, and written off to bad debt expense. Part III, Line 3: BAD DEBT EXPENSE ATTRIBUTABLE TO THE PATIENTS ELIGIBLE UNDER THE ORGANIZATIONS FINANCIAL POLICY CANNOT BE REASONABLE ESTIMATED. Part III, Line 4: Accounts receivable are reduced by an allowance for estimated uncollectible accounts. In evaluating the collectability of accounts receivable, the Hospital analyzes its past history and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for estimated 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 estimated uncollectible accounts. For receivables associated with services provided to patients who have third-party coverage, the Hospital analyzes contractually due amounts and provides an allowance for estimated uncollectible accounts and a provision for bad debts, if necessary (for example, for expected uncollectible deductibles and copayments on accounts for which the third-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 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 estimated uncollectible accounts.The Hospital's allowance for doubtful accounts for self-pay patients was approximately 91% and 94% for 2016 and 2015, respectively. In addition, the Hospital's self-pay write-offs increased approximately $1,686,000 from $18,146,000 for fiscal year 2015 to $19,832,000 for fiscal year 2016. During FY 2015, self-pay write-offs decreased due to a decrease in self-pay revenue. During FY 2016, self-pay write-offs increased due to an increase in self pay apportioned piece of commercial payor receivables. Part III, Line 8: MEDICARE COSTS REFLECT ALLOWABLE COSTS PER THE MEDICARE COST REPORT USING ACCEPTABLE ALLOCATIONS OF INDIRECT COSTS BASED ON STATISTICAL BASIS. Part III, Line 9b: Accounts known to have qualified for financial assistance are written off with an adjustment indicating indigent writeoff. Part VI, Line 2: Upson completes a triennial needs assessment. Information gathered from stakeholder interviews, community-wide surveys, discussions with the hospital leadership team, review of demographic and health status, and hospital utilization data is used to determine the priority health needs of the population. Health priorities were further developed by the CHNA Hospital Steering Committee (CHSC) after careful review of community resources available for these priorities and the future value of the priority. The following priorities were identified by the CHSC:1. Access to Care2. Obesity3. Heart Disease and Stroke4. Diabetes5. Teen Pregnancy6. Mental Health7. Drug Abuse Part VI, Line 3: UPSON REGIONAL MEDICAL CENTER INFORMS AND EDUCATES THE PATIENTS USING THE FOLLOWING PROCESSES: THE FINANCIAL ASSISTANCE POLICY AND FINANCIAL ASSISTANCE CONTACT INFORMATION IS POSTED IN THE ADMISSION AREAS, EMERGENCY DEPARTMENTS AND OTHER AREAS OF THE FACILITY IN WHICH ELIGIBLE PATIENTS ARE PRESENT. WE PROVIDE A COPY OF THE POLICY AND FINANCIAL ASSISTANCE CONTACT INFORMATION TO THE PATIENTS AS PART OF THE ADMISSION PROCESS. ADDITIONALLY, THE POLICY IS AVAILABLE ON THE HOSPITAL WEBSITE - WITH PRINTABLE APPLICATION.A SUMMARY OF THE POLICY IS ALSO INCLUDED IN THE PATIENT BILLING. WE DISCUSS WITH THE PATIENT THE AVAILABILITY OF VARIOUS GOVERNMENT BENEFITS, SUCH AS QUALIFYING FOR MEDICAID OR STATE PROGRAMS AND ASSIST THE PATIENT WITH QUALIFICATION FOR SUCH PROGRAMS, WHERE APPLICABLE. WE PROVIDE TRAINING TO THE STAFF ON FINANCIAL ASSISTANCE AND CONTRACT WITH CHAMBERLON & EDMONDS ON SCREENING OUR PATIENTS FOR MEDICAID AND/OR OTHER SOURCES OF ASSISTANCE. WE ALSO PROVIDE INFORMATION ON THE ADMISSIONS PACKAGE EXPLAINING THE AVAILABILITY, CRITERIA, AND THE PROCESS FOR APPLYING FOR FINANCIAL ASSISTANCE. OUR EFFORTS TO INFORM NON-ENGLISH SPEAKING PATIENTS ABOUT THE FINANCIAL ASSISTANCE POLICY IS PROVIDED BY AN INTERPRETER THROUGH THE USE OF LANGUAGE LINE, A TELEPHONE INTERPRETATION SERVICE. Part VI, Line 4: Upson County is located in west central Georgia and has a population of 27,153 as of 2010. In 2014, the population estimate was 26,256. Upson Regional Medical Center, a regional health care provider with 115 acute-care beds, serves this area of Georgia. The hospital is located in the county seat of Thomaston. The surrounding areas of Thomaston are diverse as far as population of rural and urban areas. The population distribution among rural and urban areas is almost split evenly53.1 percent of the population is urban and 46.9 percent is rural. The County's population is predicted to increase to 27,144 residents by 2020. The percentage of residents aged 55 and older had increased from 2010 to 2013; this identified an increased need for delivery of healthcare that serves individuals with chronic conditions. The Hispanic population had increased, and remains a small portion of the population. Part VI, Line 5: UPSON REGIONAL MEDICAL CENTER CONTINUES TO WORK COLLABORATIVELY WITH THE LOCAL HEALTH DEPARTMENTS, COUNTY EXTENSION SERVICES, CIVIC CLUBS, AND CHURCHES TO PROVIDE ANNUAL HEALTH FAIRS, SCREENINGS AND EDUCATIONAL PROGRAMS. DUE TO THE CONTINUAL DECLINE OF INDUSTRY IN THIS AREA BEGINNING WITH THE TEXTILE INDUSTRY SHUT-DOWN, MANY PEOPLE DEPEND ON THESE ANNUAL HEALTH FAIRS FOR THEIR PREVENTATIVE HEALTH CARE. THE NUMBER OF UNDERINSURED AND UNINSURED PEOPLE INCREASES EACH YEAR. UPSON REGIONAL OFFERS MANY FREE AND DISCOUNTED DIAGNOSTIC SCREENINGS AND TESTS. THIS HAS PROVIDED EARLY DETECTION FOR MANY DISEASES AS WELL AS PROMOTED HEALTH AND WELLNESS THROUGH ANNUAL CHECKUPS SINCE THAT TIME. THESE ANNUAL HEALTH FAIRS ARE A COOPERATIVE EFFORT AMONG MANY GROUPS IN OUR COMMUNITY.WE PROVIDED FREE OR DISCOUNTED TESTS AT HEALTH FAIRS, CANCER SCREENINGS, DIABETES SCREENINGS, CARDIAC SCREENINGS, EDUCATIONAL OFFERINGS AND FREE FLU IMMUNIZATIONS. Part VI, Line 7, Reports Filed With States GA 1 EDUCATION SCHOLARSHIP / LOAN ASSISTANCE 13 30720 TUITION REIMBURSEMENT 4 10273 Part I, Line 2: SCHOLARSHIP ASSISTANCE IS OFFERED TO UPSON COUNTY RESIDENTS AND FULL TIME, PART TIME AND PRN EMPLOYEES PURSUING A HEALTHCARE CAREER. EACH APPLICANT MUST COMPLETE AN APPLICATION, BE ACCEPTED BY AN ACCREDITED SCHOOL IN A HEALTHCARE PROGRAM OF THEIR CHOICE, SUBMIT TWO LETTERS OF RECOMMENDATION, A CERTIFIED COPY OF PREVIOUS EDUCATIONAL TRANSCRIPTS, AND A LETTER OF ACCEPTANCE IN THE HEALTHCARE CAREER PROGRAM, OBTAIN APPROVAL FROM THE DEPARTMENT DIRECTOR OR SENIOR MANAGEMENT, BE INTERVIEWED BY CHIEF NURSING OFFICER, MAINTAIN A 3.0 CUMULATIVE AVERAGE, SUBMIT TRANSCRIPTS OF GRADES EVERY SCHOOL TERM, AND SERVE AS AN EMPLOYEE A MINIMUM OF ONE YEAR FROM EACH SCHOOL YEAR FOR WHICH SCHOLARSHIP MONIES ARE GRANTED. TRANSCRIPTS OF GRADES MUST BE RECEIVED BEFORE REIMBURSEMENT. SHOULD THE STUDENT NOT SEEK AND MAINTAIN EMPLOYMENT WITH URMC AFTER GRADUATION, FUNDS WILL BECOME DUE AND PAYABLE IN A PRORATE FASHION BASED ON EMPLOYMENT TERM. TUITION REIMBURSEMENT IS AWARDED FULL TIME AND REGULARLY SCHEDULED PART TIME EMPLOYEES. MONIES ARE GRANTED TO COVER TUITION, BOOKS AND LABORATORY FEE. EACH APPLICANT MUST BE ENROLLED IN AN ACCREDITED COLLEGE/UNIVERSITY WITHIN A PROGRAM DIRECTLY RELATED TO THE EMPLOYEE'S PRESENT POSITION OR A FIELD THAT WILL BE OF BENEFIT TO THE MEDICAL CENTER, SEEK APPROVAL FROM MANAGEMENT, FURNISH A TRANSCRIPT OF GRADES, MAINTAIN A "C OR HIGHER AVERAGE TO BE REIMBURSED, AN EMPLOYEE MUST PRESENT A CERTIFIED COPY OF THE GRADE REPORT WITH AN AVERAGE OF "C OR HIGHER. X 1 0 X X 0 0 0 0 0 0 0 0 0 TRIPP PENN CEO (FROM JUNE) 155683 0 30000 0 15885 0 3527 0 18943 0 224038 0 0 0 John Williams CFO 211276 0 0 0 8425 0 4481 0 14183 0 238365 0 0 0 Dr Brandon M Boyce Orthopedic Surgeon 666520 0 494729 0 45250 0 5300 0 34097 0 1245896 0 0 0 DR NANCY BUTLER ENT SURGEON 446103 0 42144 0 0 0 2129 0 11863 0 502239 0 0 0 Dr Robert Solyomvari Surgeon 374933 0 220500 0 7211 0 5300 0 34037 0 641981 0 0 0 DR DARRYL KNIGHT SUrgeon 341633 0 148633 0 0 0 5300 0 34097 0 529663 0 0 0 Dr Daniel A Bridges Surgeon 447432 0 3645 0 94615 0 5300 0 39205 0 590197 0 0 0 Part I, Line 1a THE INTERIM CHIEF NURSING OFFICER AND INTERIM CHIEF EXECUTIVE OFFICER WERE PROVIDED TEMPORARY HOUSING AS PART OF THEIR CONTRACT TERMS OF EMPLOYMENT. ALSO, THE CEO TRIPP PENN WAS PROVIDED TEMPORARY HOUSING FOR THREE MONTHS. PART III PHYSICIAN BONUSES ARE PAID BASED ON RELATIVE VALUE UNITS (RVUS) ACHIEVED DURING A SPECIFIED TIME PERIOD EACH PHYSICIAN'S EMPLOYMENT CONTRACT INCLUDES A RVU GOAL. THE PHYSICIAN IS PAID BONUSES BASED ON MEETING OR EXCEEDING THE GOAL AS DETERMINED BY THEIR CONTRACT. A HOSPITAL AUTHORITY OF UPSON COUNTY 586002427 2004-12-31 10000000 RENOVATION & EXPANSION OF HOSPITAL 0 0 0 B HOSPITAL AUTHORITY OF UPSON COUNTY 586002427 2005-01-20 6000000 RENOVATION & EXPANSION OF HOSPITAL 0 0 0 A 5025000 10000000 124175 9875825 2007 0 0 1 1 B 3010000 6000000 79846 5920154 2007 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 1 0 0 0 0 0 B 0 0 0 1 0 0 0 0 0 A 0 B 0 Date Rebate Computation Performed Issuer Name: HOSPITAL AUTHORITY OF UPSON COUNTY Date the Rebate Computation was Performed: 12/30/2009 Issuer Name: HOSPITAL AUTHORITY OF UPSON COUNTY Date the Rebate Computation was Performed: 01/20/2010 Form 990, Part VI, Section A, line 3 THE ORGANIZATION HIRED HEALTHTECH MANAGMENT SERVICES TO PROVIDE THE INTERIM CEO. THE ORGANIZATION PAID $160,417 TO HEALTHTECH. Form 990, Part VI, Section B, line 11b FORM 990 WAS EMAILED TO EACH BOARD OF TRUSTEE MEMBER PRIOR TO THE IRS FILING DUE DATE FOR THEIR REVIEW. FORM 990 REVIEW WAS PLACED ON THE BOARD AGENDA FOR DISCUSSIONS SHOULD ANY QUESTIONS OCCUR. THE 990 IS REVIEWED BY THE CFO IN DETAIL PRIOR TO FILING WITH THE IRS. Form 990, Part VI, Section B, line 12c THE POLICY COVERS ALL DIRECTORS, OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION. SHOULD A MATTER COME BEFORE THE BOARD OF DIRECTORS WHICH CONSTITUTES A CONFLICT OF INTEREST, THE INDIVIDUAL INVOLVED WILL MAKE KNOWN THE POTENTIAL CONFLICT AND WITHDRAW FROM THE MEETING SO LONG AS THE MATTER SHALL CONTINUE UNDER DISCUSSION AND SHALL NOT EITHER VOTE ON THE MATTER UNDER DISCUSSION OR ATTEMPT TO INFLUENCE A DECISION OF THE GOVERNING AUTHORITY WITH RESPECT TO SUCH MATTERS, UPON WHICH THERE COULD POSSIBLY BE A CONFLICT OF INTEREST. Form 990, Part VI, Section B, line 15 IN DETERMINING COMPENSATION FOR TOP OFFICIALS, HUMAN RESOURCES OBTAINS THE COMPARABLE SALARY SURVEY AND PRESENTS IT TO THE BOARD OF DIRECTORS WHO MAKE A FINAL DECISION. THE CEO IS NOT PRESENT DURING THE DISCUSSION AND DECISION-MAKING PROCESS. DELIBERATIONS AND DECISIONS ARE DOCUMENTED IN THE MINUTES OF THE MEETING. ANNUAL MERIT ADJUSTMENT: SALARY ADJUSTMENT IS DETERMINED BY ORGANIZATIONAL PERFORMANCE AS REFLECTED IN THE SCORE OF THE ESTABLISHED PERFORMANCE MEASUREMENT INSTRUMENT. (LEM/LEADERSHIP EVALUATION MANAGEMENT). PERIODIC MARKET ADJUSTMENT: SALARY IS REVIEWED PERIODICALLY BY THE CURRENT MANAGEMENT GROUP (HEALTH TECH) AND COMPARED TO CEO SALARIES OF COMPARABLE ORGANIZATIONS TO ENSURE THAT THE CURRENT RATE IS COMPETITIVE. IN DETERMINING COMPENSATION FOR THE CFO, OTHER OFFICERS OR KEY EMPLOYEES, THE ORGANIZATION'S HUMAN RESOURCES DEPARTMENT OBTAINS COMPARABLE SALARY DATA AND PRESENTS IT TO THE GOVERNING BODY WHO MAKES THE FINAL DECISION. THE INDIVIDUAL IN THE CONSIDERATION PROCESS IS NOT PRESENT DURING THE DISCUSSION AND DECISION-MAKING PROCESS. DELIBERATIONS AND DECISIONS ARE DOCUMENTED IN THE MINUTES OF THE MEETING. ANNUAL MERIT ADJUSTMENT: SALARY ADJUSTMENT IS DETERMINED BY ORGANIZATIONAL PERFORMANCE AS REFLECTED IN THE SCORE OF THE ESTABLISHED PERFORMANCE MEASUREMENT INSTRUMENT. (LEM/LEADERSHIP EVALUATION MANAGEMENT). PERIODIC MARKET ADJUSTMENT: SALARY OF EACH OFFICER IS REVIEWED PERIODICALLY BY HUMAN RESOURCES AND APPROPRIATE OFFICER AND COMPARED TO SALARIES OF COMPARABLE ORGANIZATIONS TO ENSURE THAT THE CURRENT RATE IS COMPETITIVE. Form 990, Part VI, Section C, line 18 THE FORM 900 AND 990T IS MADE AVAILABLE UPON REQUEST. Form 990, Part VI, Section C, line 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE FOR INSPECTION, WITH NOTICE, IN THE OFFICE OF THE ORGANIZATION. Form 990, Part IX, line 11g Contract Labor: Program service expenses 2,096,257. Management and general expenses 813,457. Fundraising expenses 0. Total expenses 2,909,714. Other Fees: Program service expenses 2,167,692. Management and general expenses 3,384,096. Fundraising expenses 0. Total expenses 5,551,788. Physician Fees: Program service expenses 2,054,036. Management and general expenses 0. Fundraising expenses 0. Total expenses 2,054,036. Consulting Fees: Program service expenses 2,186. Management and general expenses 849,550. Fundraising expenses 0. Total expenses 851,736. Collections and Billing: Program service expenses 0. Management and general expenses 428,636. Fundraising expenses 0. Total expenses 428,636. Form 990, Part XII, Line 2c: THIS PROCESS HAS NOT CHANGED FROM PRIOR YEAR. UPSON MEDICAL ASSOCIATES LLC 801 WEST GORDON STREET THOMASTON GA 30286 550840991 PHYS OFC GA -993719 321382 UPSON COUNTY HOSPITAL INC UPSON REGIONAL WELLNESS CENTER LLC 801 WEST GORDON STREET tHOMASTON GA 30286 205095610 WELLNESS CENTER GA -37707 314196 UPSON COUNTY HOSPITAL INC UPSON WOMEN'S SERVICES LLC 801 WEST GORDON STREET THOMASTON GA 30286 263227893 PHYS OFC GA -855021 540854 UPSON COUNTY HOSPITAL INC UPSON FAMILY PHYSICIANS LLC 801 WEST GORDON STREET THOMASTON GA 30286 270192553 phyS OFC GA -472602 428300 UPSON COUNTY HOSPITAL INC UPSON SURGICAL ASSOCIATES LLC 801 WEST GORDON STREET THOMASTON GA 30286 275252545 PHYS OFC GA -1949757 1082593 UPSON COUNTY HOSPITAL INC OTHOPEDICS SPORTS MEDICINE & SURGERY 801 WEST GORDON STREET THOMASTON GA 30286 272123255 PHYS OFC GA -768557 424079 UPSON COUNTY HOSPITAL INC URMC MEDICAL OFFICE BUILDING LLC 801 WEST GORDON STREET THOMASTON GA 30286 474279645 MEDICAL OFFICE BUILDINGS GA 0 0 URMC HEALTH FOUNDATION PO BOX 1089 THOMASTON GA 30286 830411781 FOUNDATION GA 501(c)(3) Line 12a, I UCH - UPSON COUNTY HOSPITAL INC 1 HOSPITAL AUTHORITY OF UPSON COUNTY 801 WEST GEORGIA GORDON STREET THOMASTON GA 302860027 MANAGEMENT GA GOVT N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 URMC HEALTH FOUNDATION C 67580