2017-05-15T10:31:44-05:00 2016-06-30 481026809 Wendling Noe Nelson & Johnson LLC 534 S Kansas Ave Suite 1500 Topeka KS 666033491 990 2015-07-01 480559088 Hays Medical Center Inc HAYS 7856235000 2220 Canterbury Drive Hays KS 67601 John Jeter MD CEO 7856235000 2017-05-11 1 Heather R Eichem P01515553 7852334226 2017-05-11 2015 2021-01-29 14:40:06Z X John Jeter MD 2220 Canterbury Drive Hays KS 67601 189076096 0 X www.haysmed.com X 1944 KS Hays Medical Center is a tax-exempt charitable organization under Section 501(c)(3) of the Internal Revenue Code and is licensed by the State of Kansas Department of Health and Environment. The purpose of the Organization is to provide healthcare facilities and services for the care and treatment of inpatients and outpatients who are acutely ill or who otherwise require medical care and related services. The core purpose of the Organization is to help people be healthy. The Organization is striving to become the best tertiary care center in rural America. 17 10 1701 198 -2213 0 2130293 1720746 187242012 184376692 2887936 3582996 -245346 -689236 192014895 188991198 0 0 98323585 97916852 0 0 82934628 81295150 181258213 179212002 10756682 9779196 271006181 270493933 81736809 77118264 189269372 193375669 X Hays Medical Center is a tax-exempt charitable organization under Section 501(c)(3) of the Internal Revenue Code and is licensed by the State of Kansas Department of Health and Environment. The purpose of the Organization is to provide healthcare facilities and services for the care and treatment of inpatients and outpatients who are acutely ill or who otherwise require medical care and related services. The core purpose of the Organization is to help people be healthy. The Organization is striving to become the best tertiary care center in rural America. 0 0 149639192 185736716 Patient Care Program services consist of routine and ancillary department healthcare services provided by a healthcare organization as defined in Section 501(c)(3) of the IRS code. Admissions: Acute-4,799, Newborn ICU-40, Newborn-678, Skilled-189, Total admissions-5,706. Patient days: ICU/CPCU-6,416, Medical/Surgical-10,831, Obstetrics-1,618, Skilled-2,116, Newborn ICU-301, Newborn-1,267, Total patient days-22,549. Other statistical information: Surgical procedures-8,195, Cardiac caths-1,387, Emergency room visits-11,818, Outpatient procedures-149,312, Medical oncology service visits-6,483, Clinic visits-134,887. 149639192 1 1 0 1 0 0 0 0 0 1 1 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1 1 1 0 0 1 146 0 1 1701 1 0 0 0 0 0 0 0 0 0 0 X 17 10 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X George Harms CFO 7856235000 2220 Canterbury Drive Hays KS 67601 Alan Moore Chair 0.50 X X 0 0 0 Kenneth Beran Secretary 0.50 X X 0 0 0 Jayne Clarke Treasurer 0.50 X X 0 0 0 Daniel Schippers Board Member 0.50 X 0 0 0 Dennis Bieker Board Member 0.50 X 0 0 0 Dr Darrell Werth Physician/Board Member 40.00 X 523593 0 35514 Nancy Curtis Board Member 0.50 X 0 0 0 Deanna Doerfler Board Member 0.50 X 0 0 0 Dr Heather Harris Board Member 40.00 X 177760 0 21455 Wayne Kieffer Board Member 0.50 X 0 0 0 Mary Martin Board Member 0.50 X 0 0 0 Brian Lang Board Member 0.50 X 0 0 0 Lee Hodny MD Physician/Board Member 40.00 X 617914 0 45616 Sharon Dreher Board Member 0.50 X 0 0 0 DG Bickle Board Member 0.50 X 0 0 0 Dr Steve Rankin Physician/Board Member 40.00 X 318447 0 33789 John Jeter MD President & CEO 36.00 4.00 X X 784745 0 156635 George Harms Chief Financial Officer 36.00 4.00 X 319973 0 89947 Bryce Young Chief Operating Officer 36.00 4.00 X 347293 0 98146 Larry Watts Chief Medical Officer 36.00 4.00 X 303068 0 57360 Terry Siek Chief Nursing Officer 40.00 X 231800 0 58489 Shae Veach VP Regional Dev 36.00 4.00 X 230678 0 72677 Derwood Whittington VP Human Resources 40.00 X 218301 0 44883 Vivek Sharma Physician 40.00 X 1176354 0 41576 Alex De Carvalho Physician 40.00 X 1021975 0 33277 Gulraiz Cheema Physician 40.00 X 838342 0 43386 Sukchan Lee Physician 40.00 X 799902 0 3051 Elizabeth Ashworth Physician 40.00 X 675451 0 33070 Dale Montgomery Former VP Facilities (key employee) 40.00 X 108319 0 61 8693915 0 868932 135 1 1 0 Quest Diagnostics Inc PO Box 14730 St Louis MO 631504730 Lab Services 4185863 Southwest Kansas Emergency PhysiciansLL PO Box 674579 Detroit MI 482674579 ER Physician Services 1514973 Anesthesiologist Assoc of Hays PO Box 821 Hays KS 67601 Anesthesia Services 1013406 Huron Consulting Services LLC 3005 Momentum Place Chicago IL 606895330 Consulting Services 840314 Coresource Inc 62897 Collection Center Chicago IL 606930628 TPA fees 774405 55 1255000 465746 1720746 Net patient service revenue 621990 175778856 175778856 Services to CAH network and afill 900099 3864926 3864926 Fitness center 900099 1542413 1542413 Retail pharmacy 900099 1226269 1226269 1964228 1964228 184376692 3543433 3543433 284810 0 284810 284810 284810 124461 84898 39563 39563 39563 Cafeteria revenue 722210 557692 557692 Physician practice billing 900099 517522 517522 Nursing mother's resources 900099 140 140 -2049400 -2353 -2047047 -974046 188991198 185736716 -2213 1535949 4233135 1548557 2684578 77062046 65252720 11809326 2909613 2708248 201365 8796832 7353477 1443355 4915226 4062284 852942 769561 769561 453349 453349 187244 187244 15737731 12389308 3348423 340357 9535 330822 465766 313868 151898 2305066 1370519 934547 2017450 1644280 373170 377826 341061 36765 900151 569352 330799 2593024 2593024 11453227 8689563 2763664 1391773 1079469 312304 Medical Supplies 18299593 18299593 Pharmaceuticals 13394564 13394564 Repairs and maintenance 4072095 3510156 561939 Taxes and assessments 1472639 1449786 22853 5063734 3059828 2003906 179212002 149639192 29572810 0 328814 114480 24240943 27557694 25612463 23560672 4473358 4286254 4265761 4080242 224312503 144711442 79605934 79601061 77964201 74966439 40122242 41652532 538200 538200 13854265 14136359 271006181 270493933 25095733 24704712 75534 55464382 51229153 1101160 1184399 81736809 77118264 X 181326923 185253081 7942449 8122588 189269372 193375669 271006181 270493933 X 9779196 -5853039 180140 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 19346 0 0 0 19346 0 Part II-B, Line 1: Hays Medical Center, Inc., is a member of the Kansas Hospital Association and the American Hospital Association. Both of these organizations engage in lobbying activities for hospital and general health care interests as part of the services provided to members. 10641739 477816 304590 42502 11381643 10377772 11158 324882 72073 10641739 9933230 154338 335088 44884 10377772 9480780 106926 388512 42988 9933230 8947679 167515 427208 61622 9480780 0.58010 0.32790 0.09200 0 1 1 356356 356356 80807334 43244242 37563092 130502493 93376839 37125654 12646320 8090361 4555959 79601061 6561100 F Hedge funds 17878381 F Private equity funds 5213140 F Real estate limited partnership 6531110 F Energy limited partnership 5468801 F 41652532 Interest receivable whose use is limited by Board or indenture agreement 60952 Beneficial interest in net assets of foundations 8122588 Other receivables 2167933 Debt issue costs 703998 Estimated third party payor settlements 2837193 Intercompany receivables 243695 14136359 Estimated third-party payor settlements 1184399 1184399 X 183318299 -5853039 180140 -5672899 188991198 0 188991198 179212002 0 179212002 0 179212002 Part V, Line 4: The endowed funds held by the Hays Medical Center Foundation are used to help meet both the immediate and long range health care needs of patients of Hays Medical Center, Inc. The Hays Medical Center Foundation provides grants and assistance to Hays Medical Center, Inc., for property and equipment acquisitions, education, and community health issues. Part X, Line 2: Management is not aware of any uncertainties in income tax positions. Part XI, Line 2d - Other Adjustments: Change in beneficial interest in net assets of foundations 1 1 X 1 X 130.000000000000 1 X 1 1 0 1 1 1216708 1216708 0.00680 9194322 6351769 2842553 0.01590 10411030 6351769 4059261 0.02270 1865472 1570445 295027 0.00160 940610 85349 855261 0.00480 56549177 41828364 14720813 0.08210 5620 5620 0.00000 59360879 43484158 15876721 0.08850 69771909 49835927 19935982 0.11120 82500 82500 0.00050 82500 82500 0.00050 1 2611836 182829 56270303 56428043 -157740 X 1 1 2 1 Hays Medical Center Inc 2220 Canterbury Hays KS 67601 X X X 2 Pawnee Valley Community Hospital Inc 923 Carroll Ave Larned KS 67550 X X X X Hays Medical Center Inc 1 0 0 1 X X X X X X X X X 14 1 0 1 1 X http://www.haysmed.com/ X 1 14 1 http://www.haysmed.com 0 0 1 X 130.000000000000 400.000000000000 X X X X X 1 1 X X X 1 X http://www.haysmed.com X http://www.haysmed.com X http://www.haysmed.com X X X X X 1 X 0 X X X X 1 X 0 0 Pawnee Valley Community Hospital Inc 2 0 0 1 X X X X X X X X X 14 1 0 1 1 X htts://www.pawneevalleyhospital.com/ X http://www.pawneecountykansas.com/ X 1 14 0 1 0 1 X 130.000000000000 400.000000000000 X X X X X 1 1 X X X 1 X http://http://www.pawneevalleyhospital.com/ X http://http://www.pawneevalleyhospital.com/ X http://http://www.pawneevalleyhospital.com/ X X X X X 1 X 0 X X X X 1 X 0 0 Hays Medical Center, Inc. Part V, Section B, Line 5: The CHNA conducted in collaboration with the Ellis County Health Department identified significant health needs within the Ellis County and Hays Medical Center community. A town hall meeting was organized to provide an objective consensus building method of reviewing and prioritizing county health issues. During the Town Hall meetings, the group reflected on the size and seriousness of any health concerns cited and discussed current community health strengths. The group identified and ranked top community health concerns, and all Town Hall attendees and community members were encouraged to continue to contribute ideas by going online and taking a feedback survey that addresses any additional thoughts related to the CHNA. All Town Hall priority-setting and scoring processes involved the input of a diverse group with knowledge and/or expertise in public health as well as persons who represent the broad interest of the community served by the Hospital. Key stakeholders in attendance included representatives from: Ellis County Health Department, Ellis County EMS, United Way of Ellis County, First Care Clinic FQHC, Regional Prevention Center, Turning Point Behavioral Health, Early Childhood Connections, USD 489 School District, Ellis County Coalition for Economic Development, North Central Kansas Technical School, Via Christi Village Retirement Center, City of Hays, and Hays Medical Center. The CHNA was coordinated and produced by VVV Research and Development, Inc., from Olathe, Kansas. Pawnee Valley Community Hospital, Inc. Part V, Section B, Line 5: The CHNA was conducted in collaboration with the Pawnee County Health Department. A Town Hall meeting was organized to provide an objective consensus building method of reviewing and prioritizing county health issues. During the Town Hall meeting, the group reflected on the size and seriousness of any health concerns cited and discussed current community health strengths. The group identified and ranked top community health concerns, and all Town Hall attendees were encouraged to continue to contribute ideas by going online and taking a feedback survey that addresses any additional thoughts related to the CHNA. All Town Hall priority-setting and score processes involved the input of a diverse group with knowledge and/or expertise in public health as well as persons who represent the broad interests of the community served by the hospital. Key stakeholders in attendance included representatives from: United Way, Welcome Inn Senior Center, Center for Counseling, Angels Care Home Health, Golden Belt Foundation, Larned City Council, Burdett City Council and Garfield City Council and Rozel Community, Pawnee County Sherriff's office, Larned Police Department, Pawnee County Health Department, County Commissioners, members of the Chamber of Commerce, members of the USD 495 School Board, school nurses of USD 495, local members of the media, local religious organizations and representative of Pawnee Valley Community Hospital. The CHNA was coordinated and produced by VVV Research & Development, Inc. from Olathe, Kansas. Hays Medical Center, Inc. Part V, Section B, Line 6b: Ellis County, KS Pawnee Valley Community Hospital, Inc. Part V, Section B, Line 6b: Pawnee County, KS Hays Medical Center, Inc. Part V, Section B, Line 11: HaysMed is dedicated to continually learning, engaging, and fulfilling the health needs of the community we serve. As a result of this commitment the following is the description of the actions taken during the most recent fiscal year to address the significant health needs identified through the CHNA.Add Primary Care Services - New construction is underway to relocate the Convenient Care Clinic to a location more accessible to the community. Completion of this project is anticipated for September 2017. Recruitment efforts continue for Family Medicine and Internal Medicine providers. First Care Clinic recruited new FP to the area in April 2015. Information welcoming recruits to the community is offered during all visits and correspondence with the candidate(s). Continued efforts to improve the orientation process take place. With HaysMed's recent affiliation with the University of Kansas Health System, there is more accessibility to obtain future medical students for placement in Hays. HaysMed collaborates with the University of Kansas Medical School to provide rural rotation sites for medical students. Additionally, general surgery rotations are provided for fourth year residents at HaysMed. Completed addition/expansion of Hays Family Medicine clinic to increase availability of clinic space for future providers. First Care Clinic opened Victory Clinic in October 2015.Increase Awareness and Education about Alcohol Consumption in the Community - HaysMed continues to support local high schools with a financial donation to be used toward post-prom and post-graduation activities. Due to the loss of outside funding to Smoky Hill Foundation, no additional activity was able to take place. Increase Childcare Providers- Created a generational preschool in Hays. Efforts continue to provide adequate childcare.Improve Sources and Quality of Water - The City continues efforts to clean up storm water contamination and funds the effort via a storm water utility. The City is in the process of rebuilding its 1960 wastewater treatment facility in order to improve the quality of the effluent used to irrigate parks, ball fields, golf course, and sports complex. The improvement will also improve the quality of what is discharged into Big Creek. On the quantity side, Hays and Russell are in the process of developing the R9 Ranch in Edwards County as a long-term regional water source. The regulatory process is a lengthy one, and we are almost two years into it. Once developed, the R9 should be a 75 year source of water for Hays/Russell and the immediate region.Reduce Mental Health Isolation - First Care Clinic hired LSCSW in April 2016 to increase mental health service to the community. Evaluating telemedicine capabilities for mental health.Expand Hays Public Transportation - The City repealed all taxi regulations in 2016. This ruling resulted in a significant increase in the number of taxi companies serving the community. Uber also has a strong presence in the City. The City has not actively recruited any new firms. The City continues to assist Access transportation financially through allocations to the Care Council.Reduce Drug Abuse - Due to the loss of outside funding to Smoky Hill Foundation, no additional activity was able to take place.Increase Senior Care (Skilled Care) Options - After extensive review of the patient volumes and financial viability of the Skilled Care Unit at HaysMed, it was determined to close the unit effective March 2017.Decrease Tobacco Usage - Due to the loss of outside funding to Smoky Hill Foundation, no additional activity was able to take place.Medicaid/Uninsured - Signed practice rotation agreements with two dental schools (UMKC and A.T. Still) and have hosted two students to date. Encouraging other dental providers to accept KanCare has been challenging with the recent 4% provider cut to KanCare reimbursement. First Care Clinic is currently recruiting a second dentist. First Care Clinic has added a third dental hygienist to compensate for increased demand.Add Affordable Rent/Housing - We have not been a part of any housing development plan. The city recently updated its zoning and development regulations to make it easier and more attractive to remodel or rebuild in existing neighborhoods. This will hopefully keep those neighborhoods viable economically. Pawnee Valley Community Hospital, Inc. Part V, Section B, Line 11: Annual description of the actions taken by the Hospital during the fiscal year to address the significant health needs identified throught the most recently conducted CHNA:Build and/or develop Exercise Facilities was #1 on the health needs Priorities- with 37 votes, 22.8%. Pawnee Valley Community Hospital supported USD #495 in 2015 to pass a bond for a new elementary school and renovations to the high school. Because of the CHNA and the school districts involvement and listening to the needs of Pawnee County, they have incorporated an exercise facility, in the renovations to the high school, which will be open to the public. The wellness center is expected to be open to the public August 2017.PVCH once again had their annual fun run in June 2016. The money raised was used to help purchase equipment for high school athletes. The 2017 fun run will be geared towards younger children. The plan is to have an obstacle course along with a walk and run. The proceeds from the event will go towards purchasing gym/PE equipment for the new elementary school. LA Psycle, opened its doors in 2015 for the community to sign up for spin classes. This program continues to grow. Pride Committee added a second walking trail to the community in 2015. This walking trail goes around Camp Pawnee. PVCH staff has done community presentations for heart disease awareness. In February 2016 at half time of a local basketball game, hospital staff with the help of Larned high school students did a "Flash Mob" to promote CPR. Expand Oncology Treatment was #2 on the health needs priorities - with 25 votes, 15.4%. In order to implement an effective oncology service line, many factors must come together. We have explored the feasibility of offering oncology services and providers in Pawnee County and it was determined not to be feasible at this time. We have had the great fortune of being able to partner with the Dreiling/Schmidt Cancer Institute at HaysMed. It is vitally important to maintain the relationship with both primary care medical staff as well as specialists. This will ensure consistent continuity for our patients as they move through the continuum of their cancer treatment course. The services that PVCH provides to Oncology patients through our special nursing services department are Central Line Maintenance, Transfusions, Injections, non-chemo infusions, and removal of chemotherapy pumps.Improve Quality Air Flow was #3 on health needs priorities - with 20 votes, 12.3%. We plan to continue to look into improving air quality in Pawnee County. More research needs to be done to determine if it is feasible for PVCH to implement a plan to address air quality issues.Reducing Drug/Alcohol Abuse was #4 on health needs priorities - with 20 votes, 12.3%. The Pawnee County Health Department and Pawnee Valley Community Hospital continue to partner with The Center for Counseling through an "Improving Health in Rural Counties" grant. The grant project focuses on public mental health awareness and utilization campaign focusing on (1) recognition and understanding of the importance of mental health and substance abuse issues; (2) public recognition of local behavior health resources/services (including substance use); and (3) increased utilization of those services.Print and radio advertisements are ongoing to increase behavioral health awareness and assist with increasing understanding of available community resources. A community behavioral health resource has been created to assist linking people to appropriate treatment.Crisis mental health Screenings are being performed by telemedicine to help make the screenings more accessible and get people to assistance more rapidly.Mental health kiosks "Get a Checkup from the Neck Up" are available at the health department for people to take an anonymous screening (eight different categories) and results are given to the person and they are directed by information on the screen to access assistance.Information is provided at community health fairs on mental health and substance use issues.The Pawnee County Commissioners signed a resolution on April 3rd, 2017 for the "Stepping Up Initiative". This initiative is to help reduce the number of people with mental illnesses in jails, including those with substance abuse as three quarters of those with mental health illness in jails also have substance abuse issues. The first community partner meeting for this initiative will be April 19th and includes the following:1. Larned State Hospital2. Law Enforcement3. EMS4. Pawnee Valley Community Hospital5. The Center for Counseling6. Pawnee County Ministerial Alliance7. Community Corrections8. Family Crisis Center9. County Attorney10. Public Health11. Medical ProviderThe health department, as part of our comprehensive data collection, screens individuals accessing the health department for alcohol and substance abuse and then refers if help is needed. Provide Healthy Food Options was #5 on health needs priorities - with 14 votes, 8.6%. Pawnee Valley Community Hospital is promoting healthy eating lifestyles focusing on food labels, healthy meal options, nutrition, and portion control. In 2016 PVCH signed the healthy Kansas hospital initiative. In 2016 a healthy snack and drink vending machine was added to the ER waiting room. Candy bars and sweet snacks have been eliminated from the grab and go section of the cafeteria. We continue to offer diabetic education classes and have increased the class to a two day session. Participants eat at the facility and go through the cafeteria line and are encouraged to make healthier food choices. PVCH continues to educate children at their annual sixth grade health fair and includes education on portion control, label reading, and exercise.The health department provides educational booths on healthy food at the Pawnee County fair each summer. We provide clients with appropriate educational materials on healthy eating and refer to food and nutrition education programs such as WIC. We also refer to the local food bank and participate in the Bob Box program through the Kansas Food Bank and refer children and families to the summer lunch program and the backpack buddies program. Schools are doing a good job with providing healthy food options at concession stands as well as local convenience stores readily have healthy foods in accessible locations in the stores to encourage fresh fruits and healthy foods.The health department promotes the diabetes support group and sends out their meeting reminders each month. The diabetes support group discusses nutrition with people in attendance. Increase Access to Home Health/Hospice was #6 on health needs priorities with 11 votes, 6.8%. Continuing to look at the feasibility and what we can do to increase access to home health/hospice. We will continue to promote existing agencies and educate patients of services available. PVCH has partnered with the Kansas Heart and Stroke Collaborative and have a part time staff member that goes into the home and checks on the patient and makes sure they are following the guidelines provided by their physician, pertaining to heart and stroke. In August 2016 a contract from Gentiva Hospice was reviewed by the Utilization Review Committee. It was determined that it is not financially feasible at this time but will be re-evaluated in the future.Offer Nursing Home - Dementia Services was #7 on health needs priorities with 11 votes, 6.8%. Country Living Assisted Living facility in Pawnee County recently opened an addition to their memory care unit adding 4 additional beds for a total of 12 beds dedicated to dementia patients. We will continue to work on identifying nursing home dementia services in Pawnee County and educate entities and individuals who may be in need of these services. Hays Medical Center, Inc. Part V, Section B, Line 13b: Financial assistance may be given for catastrophic medical expenses, even if patient's income exceeds the Federal poverty guidelines. Pawnee Valley Community Hospital, Inc. Part V, Section B, Line 13b: Financial assistance may be given for catastrophic medical expenses, even if patient's income exceeds the Federal povery guidelines. Hays Medical Center, Inc. Part V, Section B, Line 22d: The Hospital used the look-back method based on actual paid claims by Medicare and all other private health insurers paying claims to the Hospital. Pawnee Valley Community Hospital, Inc. Part V, Section B, Line 22d: The Hospital used the look-back method based on actual paid claims by Medicare and all other private health insurers paying claims to the Hospital. 4 1 - St Rose Health Center Inc 3515 Broadway Great Bend KS 67530 Primary care services 2 - Hays Family Medicine 2509 Canterbury Hays KS 67601 Family medicine 3 - HaysMed Convenient Care Walk-in Clinic 2501 E 13th St Hays KS 67601 Convenient care services 4 - HaysMed Psychiatric Associates 205 E 7th St Hays KS 67601 Psychiatric services Part I, Line 7: Hays Medical Center, Inc.'s, cost accounting system was used to calculate community health improvement services, health professions education, and subsidized health services costs. A cost-to-charge ratio derived from Worksheet 2 was used to calculate financial assistance at cost and the community benefit expense attributable to serving Medicaid beneficiaries. Part I, Line 7g: Subsidized health services community benefit expenses include $54,428,723 of expenses attributable to physician clinics that have net operating losses. Part II, Community Building Activities: Hays Medical Center, Inc., helps to support the First Care Clinic in Hays, Kansas. This clinic was established to help lower income individuals receive health care at a reduced cost. Our support helps to increase the number of individuals in Hays, Kansas, who receive quality primary health care. Part III, Line 4: Text of the footnote that describes bad debt expense:Accounts receivable are reduced by an allowance for uncollectible accounts. In evaluating the collectability of accounts receivable, the HaysMed Group analyzes its past history 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. For receivables associated with services provided to patients who have third-party coverage, the HaysMed Group analyzes contractually due amounts and provides an allowance for 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 HaysMed Group 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.Part III, Line 2:Costing methodology: A cost-to-charge ratio derived from Worksheet 2 was used to calculate bad debt expense at cost.Part III, Line 3:Methodology for bad debt cost for financial assistance eligible: This amount was estimated based on historical information from our collection agency on the percentage of accounts referred to collection whose guarantor was indigent. Part III, Line 8: The Medicare cost report was the costing methodology used to determine Medicare allowable costs. Allowable costs of care reported on line 6 were determined using amounts from Worksheet D, Part V and Worksheet D-1 in the Hays Medical Center, Inc., Medicare cost report for the fiscal year ended June 30, 2016. Part III, Line 9b: Whenever possible, the customer service representatives (CSR's) of Hays Medical Center, Inc., try to determine the estimated self-pay balance prior to the patient receiving services. FAP eligibility is first considered at this point in time. In addition, if full payment is not received or if payment is not made within 30 days, the CSR contacts the patient. If it is determined that at least a 2-year payment plan cannot be established with the patient, the CSR will screen for charity care and request that the charity care application be completed by the patient. Part VI, Line 3: Information regarding the Hays Medical Center, Inc., charity care program is located on the Hays Medical Center, Inc., website for patients and community members to view, and the financial assistance application is also on the website to print off and complete. A financial assistance policy summary is included with every statement that is sent to an uninsured patient. In addition, if a customer service representative of Hays Medical Center, Inc., contacts a patient about a bill and in visiting with them they determine that the patient could possibly qualify for the Hospital's charity care policy, they will send the application to the patient as well. Part VI, Line 4: Hays Medical Center, Inc., is located in Hays, Kansas, which has a population of approximately 21,000 people as of the 2015 population estimates per the U.S. Census Bureau. One of the State of Kansas Regents universities is also located in Hays, Kansas, so the population includes many college-aged students. The median household income of Hays, Kansas, is approximately $43,000. Approximately 17.7% of the population was below the poverty line. Almost 6% of the Hospital's revenue is from services provided to patients eligible for Medicaid. Hays Medical Center, Inc., is the only hospital in the city of Hays. In addition, since this is a rural area and because it is the only hospital providing tertiary level care in the region, Hays Medical Center, Inc., provides certain services to the whole western half of the State of Kansas. Part VI, Line 5: Hays Medical Center, Inc., promotes the health of the community by extending medical privileges to most qualified, local physicians. In addition, the majority of the Board of Directors live and work in the city of Hays, but they are not employed by Hays Medical Center, Inc. Part VI, Line 6: Hays Medical Center, Inc., is not a part of an affiliated health care system. X 1 1 X X X X 1 1 0 0 0 1 0 0 0 Dr Darrell Werth Physician/Board Member 523019 0 574 0 0 0 15900 0 19614 0 559107 0 0 0 Dr Heather Harris Board Member 176185 0 0 0 1575 0 10687 0 10768 0 199215 0 0 0 Lee Hodny MD Physician/Board Member 410630 0 201284 0 6000 0 15595 0 30021 0 663530 0 0 0 Dr Steve Rankin Physician/Board Member 240084 0 16263 0 62100 0 4001 0 29788 0 352236 0 0 0 John Jeter MD President & CEO 554238 0 208446 0 22061 0 130202 0 26433 0 941380 0 0 0 George Harms Chief Financial Officer 252293 0 67680 0 0 0 63797 0 26150 0 409920 0 0 0 Bryce Young Chief Operating Officer 273065 0 74228 0 0 0 68431 0 29715 0 445439 0 0 0 Larry Watts Chief Medical Officer 215637 0 87431 0 0 0 42730 0 14630 0 360428 0 0 0 Terry Siek Chief Nursing Officer 192884 0 38916 0 0 0 48752 0 9737 0 290289 0 0 0 Shae Veach VP Regional Dev 189274 0 37943 0 3461 0 45732 0 26945 0 303355 0 0 0 Derwood Whittington VP Human Resources 161834 0 34865 0 21602 0 26182 0 18701 0 263184 0 0 0 Vivek Sharma Physician 517910 0 658332 0 112 0 15900 0 25676 0 1217930 0 0 0 Alex De Carvalho Physician 571005 0 450970 0 0 0 15900 0 17377 0 1055252 0 0 0 Gulraiz Cheema Physician 569240 0 269102 0 0 0 15900 0 27486 0 881728 0 0 0 Sukchan Lee Physician 520539 0 277263 0 2100 0 0 0 3051 0 802953 0 0 0 Elizabeth Ashworth Physician 561682 0 0 0 113769 0 15900 0 17170 0 708521 0 0 0 Dale Montgomery Former VP Facilities (key employee) 0 0 0 0 108319 0 0 0 61 0 108380 0 0 0 Part I, Line 1a Benefits identified include tax indemnification on health claims. This benefit is available to the CEO and is included in taxable income. Part I, Lines 4a-b Severance payments: Dale Montgomery - $108,319 Contributions to plan: John Jeter, M.D. - $114,302 George Harms - $47,897 Bryce Young - $52,531 Larry Watts - $26,830 Terry Siek - $34,823 Shae Veach - $33,292 Derwood Whittington - $22,799 Part I, Line 6 A portion of incentive compensation for officers and key employees is determined by net earnings exceeding budget for the fiscal year. A Kansas Development Finance Authority 481066589 48543BLY2 2010-11-02 46930167 Refinancing of previous bond and equipment 0 0 0 B Kansas Development Finance Authority 481066589 2016-06-14 9970000 Refinancing of previous bond 0 0 0 A 5415000 46930167 667574 29962593 16300000 2012 1 0 1 1 B 9970000 157820 9812180 2006 1 0 1 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 A 0 0 1 0 0 0 0 0 1 B 0 0 1 0 0 0 0 0 1 A 1 B 1 Ann Jeter Family member of John Jeter, CEO 12880 Payments for consulting services 0 Jeter Law Firm Partnership more than 5% owned by family member of John Jeter, CEO 1199 Payments for legal services 0 Lynette Pfannenstiel Family member of D.G. Bickle, board member 104262 Employment 0 Arlene Werth Family member of Darrell Werth, MD, board member 71198 Employment 0 Donita Wolf Family member of Ken Beran, board member 75421 Employment 0 Carol Young Family member of Bryce Young, COO 21339 Employment 0 Dr Ross Buckles Family member of Dr. Heather Harris, board member 334407 Employment 0 Form 990, Part VI, Section B, line 11 Form 990 was reviewed with the officers and Board Finance committee. Form 990, Part VI, Section B, line 12c Officers, directors, and key employees, along with all associates, are required to complete a conflict of interest statement annually. The statements are used to monitor and enforce compliance with the policy. Form 990, Part VI, Section B, line 15 The CEO's, officers', and key employees' salaries are reviewed annually by an independent consulting group and the Compensation Committee, which is made up of members of the Board. Form 990, Part VI, Section C, line 19 These documents are not made available to the public. Financial statements are released to bond holders on a quarterly basis. Form 990, Part XI, line 9: Change in beneficial interest in net assets of foundations 180,140. Hays Medical Center Foundation 2220 Canterbury Hays KS 67601 481179684 Provide grants and allocations to Hays Medical Center, Inc. KS 501(c)(3) Line 11a, I Hays Medical Center Inc 1 HaysMed Partners Inc 2220 Canterbury Hays KS 67601 270877152 Owns management contract for Pawnee Valley Community Hospital KS 501(c)(3) Line 3 Hays Medical Center Inc 1 Pawnee Valley Community Hospital Inc 2220 Canterbury Hays KS 67601 481253246 Hospital operated by Hays Medical Center KS 501(c)(3) Line 3 HaysMed Partners Inc 1 Hadley Foundation Inc 1200 Main Hays KS 67601 481107034 Support for Hays Medical Center KS 501(c)(3) Line 11c, III-FI 0 0 0 1 1 0 0 0 0 0 1 0 1 1 1 1 0 1 0 0 Hays Medical Center Foundation C 1255000 Actual cash Hays Medical Center Foundation Q 274024 Actual cost Pawnee Valley Community Hospital Inc L 536307 Actual cost Pawnee Valley Community Hospital Inc O 376061 Actual cost Pawnee Valley Community Hospital Inc Q 2277000 Contractual formula Pawnee Valley Community Hospital Inc D 63621 Actual cost