2017-05-11T13:44:47-05:00 2016-06-30 440160260 BKD LLP 910 E St Louis St Springfield MO 658062523 990 2015-07-01 251765538 Tioga Health Care Providers Inc TIOG 5703268753 1705 Warren Ave No 302 Williamsport PA 17701 Eric D Pohjala Executive Vice President/CFO 5703213175 2017-05-11 1 Brian D Todd P00422601 4178658701 2015 2021-01-29 14:40:06Z X Steven P Johnson 700 High Street Williamsport PA 17701 9192376 0 X SUSQUEHANNAHEALTH.ORG X 1995 PA Tioga Health Care Providers is a subsidiary of UPMC Susquehanna. The mission of UPMC Susquehanna and affiliates is as follows: To extend God's healing love by improving the health of those we serve. Our vision is to create a world-class health system. Our values are to carefully place our patients and their families first, share ownership with all of our caregivers and lead with a servant's heart. 16 11 65 0 0 0 0 0 9206331 9180962 12246 11414 -35709 0 9182868 9192376 0 0 0 0 10232526 10408762 0 0 0 3401151 3832794 13633677 14241556 -4450809 -5049180 5020265 8521474 19357716 27908105 -14337451 -19386631 X Tioga Health Care Providers is a subsidiary of UPMC Susquehnanna The mission of SHS is as follows: To extend God's healing love by improving the health of those we serve. Our vision is to create a world-class health system. Our values are putting patients first, sharing ownership and being servant leaders. 0 0 13921968 9180962 Tioga Health Care Providers (THCP) is comprised of a group of emergency, internal medicine, and specialty physicians. The services primarily serve Tioga county. For the fiscal year ended June 30, 2016 there were approximately 43,170 outpatient visits and 6,209 inpatient visits for THCP. 13921968 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 1 0 0 1 65 1 0 0 0 0 0 0 0 0 0 0 X 16 11 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 0 0 0 PA X UPMC Susquehanna Medical Group Finance 5703268756 1705 Warren Ave Suite 302 Williamsport PA 17701 Ronald V Defeo Jr Director 2.00 4.00 X 0 0 0 Ann S Pepperman Esquire Chairperson 2.00 4.00 X X 0 0 0 Dsvie Jane Gilmour Ph D Vice-Chairperson 2.00 2.00 X X 0 0 0 Sister Teresa Ann Jacobs Secretary 2.00 4.00 X X 0 0 0 Ronald E DiSimone MD Director 2.00 42.00 X 0 1066958 34314 Steven P Johnson President/CEO UPMC Susquehanna 2.00 50.00 X X 0 832199 35182 Daniel A Klingerman Director 2.00 2.00 X 0 0 0 Lynda Livingston Director 2.00 4.00 X 0 0 0 Philip H Johnson Director 2.00 2.00 X 0 0 0 James E Mothersbaugh Director 2.00 2.00 X 0 0 0 Alexander R Nesbitt MD Director 2.00 46.00 X 0 222603 30549 Kevin Kist MD Director 2.00 46.00 X 0 432065 34767 Dr J Dennis Murray Director 2.00 4.00 X 0 0 0 Glenn Poirer Director 2.00 4.00 X 0 0 0 Thomas M Owlett Esquire Director 2.00 4.00 X 0 0 0 Jill A Burns MD Director 40.00 2.00 X 296503 0 37541 Eric D Pohjala Exec VP/CFO 2.00 40.00 X 0 255157 27349 Jan E Fisher Exec VP/COO 2.00 40.00 X 0 459806 31992 David Lopatofsky MD Exec VP/CMO 2.00 40.00 X 0 437276 38887 Donald Golobek Physician 40.00 X 709052 0 28225 Robert E Metts MD Physician 40.00 X 334583 0 19149 Perry E Doan Jr MD Physician 40.00 X 362134 0 39000 Rhichard M Thompson DO physician 40.00 X 356783 0 32124 Donald Shaw MD Physician 40.00 X 355161 0 33128 Charles J Santangelo Former Evec VP/CFO - Retired5/2/16 0.00 40.00 X 0 338073 24988 William C McCauley MD Former Exec VP/CMO Retired /Per Diem 1/31/15 0.00 40.00 X 0 185372 4271 Ronald J Butler Former Evec VP/CBO - Retired 4/15/16 0.00 40.00 X 0 518626 13502 2414216 4748135 464968 31 1 1 0 Medicus Emergency Room Service 22 Roulston Rd Windham NH 03087 Locum Services 563110 CompHealth Medical Staffing PO Box 972651 Dallas TX 75397 Locum Services 455295 Alliance Recruiting Resource Inc PO Box 678416 Dallas TX 75267 Locum Services 123192 3 Emergency Department 621111 2382344 2382344 Internal Medicine 621111 1526753 1526753 Inter-Entity SSA 621110 1177584 1177584 Anesthesia 621111 888986 888986 General Surgery 621111 785058 785058 2420237 2420237 9180962 11414 11414 9192376 9180962 0 11414 X 296503 296503 8697127 8605061 92066 290856 288056 2800 714105 700204 13901 410171 403128 7043 130612 130612 1587096 1541077 46019 6506 6506 367246 357603 9643 943 943 346393 345389 1004 2914 2576 338 64175 63203 972 53603 39424 14179 632005 631499 506 Provision for Doubtful 507264 507264 Maintenance Contracts 55596 55506 90 Books/Subscriptions/Due 38316 37901 415 Minor Equipment 24359 24359 15766 15766 14241556 13921968 319588 0 220420 1914637 1008358 1443101 182466 136612 116302 68741 887084 448741 173218 438343 3319501 4520040 5020265 8521474 1145641 1694204 18212075 26213901 19357716 27908105 X -14337451 -19386631 -14337451 -19386631 5020265 8521474 -5049180 0 X 0 1 X 1 0 X X 1 Soldiers and Sailors Memorial Hospital 232176963 3 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 637888 448741 189147 249196 249196 438343 Due From Affiliates 4520040 4520040 Estimated Legal Liabilities Cost 159960 Due to Affiliates 26053941 26213901 8685112 -507264 -507264 9192376 0 9192376 13734292 0 13734292 507264 507264 14241556 Part X Line 2 Management has evaluated their income tax positions under the guidance included in ASC 740. Based on that review, management has not identified any material uncertain tax positions to be recorded or disclosed in the financial statements. Part XI Line 2d Bad Debt $(507,264) Part XII Line 4b Bad Debt $507,264 0 0 0 0 0 1 0 0 0 Ronald E DiSimone MD Director 0 1031528 0 0 0 35430 0 9950 0 24364 0 1101272 0 0 Steven P Johnson President/CEO UPMC Susquehanna 0 668195 0 133858 0 30146 0 15925 0 19257 0 867381 0 0 Alexander R Nesbitt MD Director 0 219808 0 0 0 2795 0 12116 0 18433 0 253152 0 0 Kevin Kist MD Director 0 333862 0 10206 0 87997 0 9950 0 26817 0 468832 0 0 Jill A Burns MD Director 247243 0 44446 0 4814 0 9950 0 27591 0 334044 0 0 0 Eric D Pohjala Exec VP/CFO 0 252402 0 0 0 2755 0 9720 0 17629 0 282506 0 0 Jan E Fisher Exec VP/COO 0 409956 0 36987 0 12863 0 9950 0 22042 0 491798 0 0 David Lopatofsky MD Exec VP/CMO 0 412757 0 18458 0 6061 0 11275 0 27612 0 476163 0 0 Donald Golobek Physician 706126 0 0 0 2926 0 7950 0 20275 0 737277 0 0 0 Robert E Metts MD Physician 323726 0 0 0 10857 0 9800 0 9349 0 353732 0 0 0 Perry E Doan Jr MD Physician 312613 0 2500 0 47021 0 9950 0 29050 0 401134 0 0 0 Rhichard M Thompson DO physician 353904 0 0 0 2879 0 9950 0 22174 0 388907 0 0 0 Donald Shaw MD Physician 296307 0 6100 0 52754 0 9950 0 23178 0 388289 0 0 0 Charles J Santangelo Former Evec VP/CFO - Retired5/2/16 0 186916 0 71895 0 79262 0 9950 0 15038 0 363061 0 0 William C McCauley MD Former Exec VP/CMO Retired /Per Diem 0 108272 0 45384 0 31716 0 0 0 4271 0 189643 0 0 Ronald J Butler Former Evec VP/CBO - Retired 4/15/16 0 112293 0 32105 0 374228 0 9950 0 3552 0 532128 0 0 Part I, Line 3 The Williamsport Hospital EIN #24-0795508, a related organization, uses the following resources to establish the compensation of the top management officials: compensation committee, independent compensation consultant, written employment contract, compensation survey or study, and approval by the board. Part I, Line 6 Bonuses may be paid to a physician contingent upon the practice's net income. The practice's net income is determined from total charges less contractual adjustments less practice expense. A Physician's compensation may be increased by an amount equal to the excess net income. In order for the Leadership Team to participate in the annual Variable Compensation Incentive Program (VCIP), a minimum operating margin must be achieved for the most recently completed year on a consolidated system-level basis. Individual goals and objectives related to the VCIP may also include individual entity operating performance. For FY 2016, the minimum threshold was met that would trigger a VCIP payment. In December 2015, President/CEO Steven P. Johnson received a variable compensation award in the amount of $133,858. Form 990, Part VI, Section A, line 1 All 1099s were issued by UPMC Susquehanna, EIN 23-2751183. All expenses are then allocated back to all related entities. Form 990, Part VI, Section A, line 6 UPMC Susquehanna, EIN #23-2751183, is the sole member of the governing body Form 990, Part VI, Section A, line 7a UMPC Susquehanna, EIN 23-2751183, may elect or remove members of the governing body. Form 990, Part VI, Section A, line 7b All the business and affairs of the corporation shall be managed and controlled by the Board of Directors, subject to the oversight of the Member of the management and operation of the corporation, except that the following powers are reserved exclusively to the sole Member of the corporation, and no attempted exercise of any such powers by anyone other than the sole Member shall be valid or of any force or effect whatsoever. The sole member shall exercise its power through its Board of Directors. The Member shall have exclusive authority to exercise the following powers: A. To approve the appointment and removal of the President of the corporation. B. To elect and remove, with or without cause, a Director of the corporation. C. To establish the overall policy and long range plans of the corporation, determine or change the mission of the corporation, approve the programs, and services of the corporation, and monitor and maintain the philosophy, goals and purposes for which the corporation was formed and exists. D. To adopt, amend or repeal the Articles of Incorporation or the bylaws. E. To establish requirements for a unified budget, the approval of new capital debt, any increment to any existing capital debt, and/or any change in the capital debt obligations of the corporation. F. To establish requirements for the approval of the acquisition, purchase, sale, leasing outside the ordinary course of business, transfer outside the ordinary cause of business or encumbrance outside the normal course of business of land or buildings and the construction of demolition of buildings owned by the corporation. G. To require a certified audit of corporate funds at any time. H. To approve any guaranty of indebtedness of any person, the granting of any security interest in or the creation of any encumbrance on any asset of the corporation outside the ordinary course of business, or any transfer of any asset of the corporation outside the normal course of business, except transfers between or among affiliated corporations. I. To approve any merger, consolidation, organization, reorganization, joint venture or other modification of corporate structure or affiliations affecting to autonomy, governance or operations of the corporation. J. To dissolve or terminate the existence of the corporation and determine the distribution of assets upon such termination or dissolution, as provided in the bylaws. K. To appoint annually the external fiscal auditor of the corporation. L. To approve the nominees for elected officers of the Board of Directors of the corporation and to return the list of approved nominees to the Board of Directors for election. M. To remove any elected officer of the corporation. N. To approve the annual capital and operating budget of the corporation. O. To coordinate managed care plans, including decisions concerning entry into or renewal of ay contract or agreement relating thereto. Form 990, Part VI, Section B, line 11 A high-level overview of Forms 990 is presented to the parent Board of Directors (UPMC Susquehanna, 23-2751183) before filing and complete drafts of all returns are made available to all Board members through the CEO's and CFO's office. Form 990, Part VI, Section B, line 12c As required by law, SPS policy states that all members of the Board of Managers must sign a statement each year disclosing any conflict of interest that may arise and agree to abstain when issues involving those parties with conflicting interests are called to motion. Any conflicts of interest are reviewed by the System's attorneys. Form 990, Part VI, Section B, line 15 The board of directors, through the Executive Committee, retains an independent outside consultant to provide guidance with respect to the annual establishment of the rebuttable presumption or reasonableness relative to executive compensation and benefits. The consultant annually provides detailed market information from its annual Executive Compensation Survey of Health Systems. In addition, other regional survey data is provided in order to supply the health system with a "national" picture of compensation. With this process established, the executive compensation committee takes the proper steps to educate the Board of Directors to understand all of the above mentioned oversight and to appropriately prepare them for community or media inquiry. In addition, the Board is made aware of the form 990 and its role in the communication of information to the public. Form 990, Part VI, Section C, line 19 The organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Form 990, Part IX, line 11g Billing Service Fees: Program service expenses 391,402. Management and general expenses 0. Fundraising expenses 0. Total expenses 391,402. Inter Entity Tioga: Program service expenses 1,100. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,100. Inter Entity Hskpg Tioga: Program service expenses 18,785. Management and general expenses 0. Fundraising expenses 0. Total expenses 18,785. Other Purchased Services: Program service expenses 1,128,340. Management and general expenses 46,019. Fundraising expenses 0. Total expenses 1,174,359. Inter Entity Purchased Services: Program service expenses 1,450. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,450. Laurel Health System Inc 22 Walnut St Wellsboro PA 16901 240795488 Support entities affiliated with Laurel Health PA 501(c)(3) Line 11b, II UPMC Susquehanna 0 Laurel Realty 22 Walnut St Wellsboro PA 16901 231403678 Own and manage real estate in support of Laurel Health PA 501(c)(2) N/A UPMC Susquehanna 0 Laurel Management Services 22 Walnut St Wellsboro PA 16901 251644910 Management consulting and supervisory services PA 501(c)(3) Line 11b, II UPMC Susquehanna 0 Soldiers and Sailors Memorial Hospital 32-36 Central Ave Wellsboro PA 16901 232176963 Operate acute care hospital PA 501(c)(3) Line 3 UPMC Susquehanna 0 UPMC Susquehanna 1205 Grampian Blvd Williamsport PA 17701 232751183 Coordinate & manage the delivery of healthcare PA 501(c)(3) Line 11b, II N/A 0 The Green Home 37 Central Ave Wellsboro PA 16901 240804365 Operate skilled nursing & assisted living facility PA 501(c)(3) Line 9 UPMC Susquehanna 0 Divine Providence Hospital 110 Grampian Blvd Williamsport PA 17701 240799343 Hospital PA 501(c)(3) Line 3 UPMC Susquehanna 0 Muncy Valley Hospital 215 E Water St Muncy PA 17756 240806023 Hospital PA 501(c)(3) Line 3 UPMC Susquehanna 0 The Williamsport Hospital 700 High St Williamsport PA 17701 240795508 Hospital PA 501(c)(3) Line 3 UPMC Susquehanna 0 Susquehanna Health Foundation 1100 Grampian Blvd Williamsport PA 17701 232743470 Fundraising for affiliated entities PA 501(c)(3) Line 11a, I UPMC Susquehanna 0 Susquehanna Physician Services 1201 Grampian Blvd Williamsport PA 17701 232449454 Physician Services & MRI Services PA 501(c)(3) Line 3 UPMC Susquehanna 0 Williamsport Area Ambulance Service Cooperative 700 Health St Williamsport PA 17701 232416166 Ambulance Transports PA 501(c)(3) Line 9 N/A 0 Laurel Health Foundation 22 Walnut St Wellsboro PA 16901 251810488 Fundraising for affiliated entities PA 501(c)(3) Line 11a, I UPMC Susquehanna 0 North Penn Comprehensive Health Services 22 Walnut St Wellsboro PA 16901 231889724 Provide general health and social service programs PA 501(c)(3) Line 3 Laurel Health System 0 Susquehanna Health Innovation 700 High St Williamsport PA 17701 471600873 Supporting organization of affiliated entities PA 501(c)(3) Line 11a, I UPMC Susquehanna 0 Community Basket LLC 1205 Grampian Blvd Williamsport PA 17701 201195739 Rents real estate PA UPMC Susquehanna Excluded from tax 0 0 Tyoga Carenet 114 East Avenue Wellsboro PA 16901 251810967 Integrate Healthcare regionally PA UPMC Susquehanna C 0 Susquehanna Health System Insurance Network LTD PO Box 1159 Grand Caymans CJ 980458722 Captive Insurance Company CJ UPMC Susquehanna 0 Susquehanna Ventures Inc 1201 Grampian Blvd Williamsport PA 17701 232470263 Pharmacy & Infusion Services PA UPMC Susquehanna C 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 1 0 0 0 Laurel Realty J 291636 Market Value Schedule R, Part III Identification of Related Organizations Taxable as Partnership: Name of Related Organization: Community Basket, LLC. Direct Controlling Entity: Susquehanna Health System & Susuquehanna Health Foundation Schedule R, Part IV Susquehanna Health System Insurance Network, LTD (SHSIN), EIN #98-0458722 is a foreign corporation, incorporated under the laws of the Cayman Islands. There are no income, capital, or premium taxes levied in the Cayman Islands and SHSIN has been granted an exemption until September 2022 for any such taxes that might be introduced. SHSIN's sole shareholder, UPMC Susquehanna EIN #23-2751183, is a 501(c)(3) organization exempt from federal income taxes. SHSIN conducts no business in the United States. It files an 1120F protective filing which implies that its income is not subject to US federal income tax.