2017-05-11T13:27:58-05:00 2016-06-30 BKD LLP 910 E St Louis Street Suite 200 Springfield MO 65806 990 2015-07-01 232449454 Susquehanna Physician Services SUSQ 5703207900 1705 Grampian Blvd No 302 Williamsport PA 17701 Eric D Pohjala Executive VP/CFO 5703213171 2017-05-11 1 Brian D Todd P00422601 4178658701 2015 2021-01-29 14:40:06Z X Susquehanna Health Medical Group Steven P Johnson 777 Rural Avenue Williamsport PA 17701 97856415 0 X www.susquehannahealth.org X 1987 PA To effect a continuum of compassionate care which assures quality for our patients and value for those who provide it. 16 11 594 30 0 0 25390300 28168231 65637069 69688184 0 0 0 0 91027369 97856415 0 0 0 0 73268448 79223951 0 0 0 17982116 18524256 91250564 97748207 -223195 108208 15457219 16774823 11889587 13098983 3567632 3675840 X Susquehanna Physician Services 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 an integrated community health system that delivers world class care. 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. 0 0 92296620 69688184 Susquehanna Physician Services (SPS) is comprised of a groupof primary care and specialty physicians. The services primarily serve Lycoming and surrounding counties. For fiscal year ended June 30, 2016there were approximately 705,412 patient visits for SPS. 92296620 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 594 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 Management 5703268756 1705 Warren Avenue 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 Davie Jane Gilmour Ph D Vice Chairperson 2.00 2.00 X X 0 0 0 Sister Teresa Ann Jacobs Secretary 2.00 6.00 X X 0 0 0 Ronald E DiSimone MD Director 42.00 2.00 X 1066958 0 34314 Lynda Livingston Director 2.00 4.00 X 0 0 0 Steven P Johnson President/CEO 2.00 50.00 X X 0 832199 35182 Daniel A Klingerman Director 2.00 2.00 X 0 0 0 Philip H Johnson Director 2.00 2.00 X 0 0 0 James E Mothersbaugh Treasurer 2.00 2.00 X X 0 0 0 Alexander R Nesbitt MD Director 42.00 6.00 X 222603 0 30549 Kevin W Kist Jr DO Director 42.00 6.00 X 432005 0 36767 Dr J Dennis Murray Director 2.00 4.00 X 0 0 0 Glenn Poirier Director 2.00 4.00 X 0 0 0 Jill Burns MD director 2.00 40.00 X 0 296503 37541 Thomas M Owlett Esquire Director 2.00 4.00 X 0 0 0 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 - hired 2/2015 42.00 2.00 X 488432 0 37934 Michael J Lazar MD Physician 40.00 X 820204 0 36308 Sabrina Dowd Physician 40.00 X 785221 0 33776 Donald T Nardone MD Physician 40.00 X 747289 0 37704 Michael V Hoffman MD Physician 40.00 X 855847 0 33919 John H Bailey MD physician 40.00 X 896944 0 34264 Charles J Santangelo Former Exsc VP/CFO-Retired 5/2/15 0.00 0.00 X 0 338073 24988 Ronald J Butler Former Exec VP/CBO Retired 4/15/15 0.00 2.00 X 0 518626 13502 William C McCauley MD Former Exec VP/CMO Retired 1/31/15 0.00 X 185372 0 4271 6500875 2700364 490360 156 1 1 0 Comphealth Medical Staffing PO Box 972651 Dallas TX 75397 Temporary Employment 2192000 Locumtenens Com PO Box 405547 Atlanta GA 30384 Temporary Employment 757327 Cerner Health Services PO Box 959167 St Louis MO 63198 Software 533827 Weatherby Locums PO Box 972633 Dallas TX 75397 temporary Employment 509965 The Advisory Board Company PO Box 79461 Baltimore MD 21279 Decision Support 315120 8 28168231 28168231 Net Patient Services 621110 55588571 55588571 Inter-Entity SSA 621110 10687743 10687743 Other Revenue 621110 2500248 2500248 Inter-Entity Revenue 621110 640859 640859 Capitation Payments 621110 270763 270763 69688184 97856415 69688184 0 0 1721566 1721566 65208513 62698735 2509778 2208151 2093401 114750 6871259 6560510 310749 3214462 3064850 149612 1695564 56 1695508 22145 22145 1983737 1983737 105085 105085 3332509 3326065 6444 800458 489419 311039 3151504 2913767 237737 85383 81592 3791 535630 501592 34038 194642 194642 1481419 1447331 34088 1935103 1935103 Provision For Bad Debt 2565225 2565225 Books Subscriptions Due 371134 346397 24737 Minor Equipment 264718 245402 19316 97748207 92296620 5451587 0 1206024 1647318 5655336 5457839 121405 121834 1414798 1486108 275983 407023 459777 518080 21723852 15099471 6230591 6624381 20857 0 72448 512240 15457219 16774823 6323742 7881972 2987253 2755291 2578592 2461720 11889587 13098983 X 3567632 3675840 3567632 3675840 15457219 16774823 108208 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 41973 41973 373321 373154 167 2231059 1486520 744539 15012434 11510230 3502204 4065065 1729567 2335498 6624381 Third Party Payors 370004 Due To Affliates 2091716 2461720 67118927 -2564325 -2564325 69683252 28173163 28173163 97856415 95182982 0 95182982 2565225 2565225 97748207 Schedule D Part X Line 2- Management has evaluated their income tax positions under the guidance included in ASC 740. Based on their review, management has not identified any material uncertain tax positions to be recorded or disclosed in the financial statements. Part XII Line 2d - Provision for doubtful accounts of -$2,565,225 and net assets released from restriction $900 are not included in net revenue on the audited financial statements. Part XII Line 4b- Susquehanna Physician Services received financial support from the following related entities The Williamsport Hospital & Medical Center $11,694,779 Divine Providence Hospital $11,872,861 Muncy Valley Hospital $4,600,591 and TRNA transfers from affiliates $4,932 Part XIII Line 4b - Provision for doubtful accounts of $2,565,225 are not included in expenses on the audited financial statements. Central America 1 0 Program Services Captive insurance company 1935103 1 0 0 0 1 0 1935103 0 1935103 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Ronald E DiSimone MD Director 1031528 0 0 0 35430 0 9950 0 24364 0 1101272 0 0 0 Steven P Johnson President/CEO 0 668195 0 133858 0 30146 0 15925 0 19257 0 867381 0 0 Alexander R Nesbitt MD Director 219808 0 0 0 2795 0 12116 0 18433 0 253152 0 0 0 Kevin W Kist Jr DO Director 333862 0 10206 0 87937 0 9950 0 26817 0 468772 0 0 0 Jill Burns MD director 0 247243 0 44446 0 4814 0 9950 0 27591 0 334044 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 - hired 2/2015 408670 0 61045 0 18717 0 11275 0 26659 0 526366 0 0 0 Michael J Lazar MD Physician 714057 0 60000 0 46147 0 9950 0 26356 0 856510 0 0 0 Sabrina Dowd Physician 743372 0 41195 0 654 0 9950 0 23826 0 818997 0 0 0 Donald T Nardone MD Physician 524706 0 0 0 222583 0 9950 0 27754 0 784993 0 0 0 Michael V Hoffman MD Physician 798184 0 57017 0 646 0 9950 0 23969 0 889766 0 0 0 John H Bailey MD physician 576569 0 210620 0 109755 0 9950 0 24314 0 931208 0 0 0 Charles J Santangelo Former Exsc VP/CFO-Retired 5/2/15 0 186916 0 71895 0 79262 0 9950 0 15038 0 363061 0 0 Ronald J Butler Former Exec VP/CBO Retired 4/15/15 0 112293 0 32105 0 374228 0 9950 0 3552 0 532128 0 0 William C McCauley MD Former Exec VP/CMO Retired 1/31/15 108272 0 45384 0 31716 0 0 0 4271 0 189643 0 0 0 Part I, Line 5 Part I, Line 3 The Williamsport Hospital EIN#24-0795508, a related organization, uses the following resources to establish the compensation of top management officials: compensation committee, independent compensation consultant, written employment contract, compensation survey or study, and approval by the board. Part I, Line 6 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. John H Bailey MD Employee Sign On X 100000 50748 0 0 1 Michael J Lazar MD Employee Recruitment X 120000 31812 0 0 1 David Lopatofsky MD Employee Educational Assistance X 43757 39274 0 0 1 121834 Schedule L, Part 2, Loans To and From Interested Persons: Name of Person: John H. Bailey, MDDisqualified Person Code: 1 of top 5 highest compensatedPurpose of Loan: Sign on BonusOriginal Amount: $100,000Balance Due: $50,748Loan in Default? = NoApproved by Board or Committee? = NoWritten Agreement? = Yes Schedule L, Part 2, Loans To and From Interested Persons Name of Person: Michael J. Lazar, MDDisqualified Person Code: 1 of top 5 highest compensatedPurpose of Loan: Recruitment BonusOriginal Amount: $120,000Balance Due: $31,812Loan in Default? = NoApproved by Board or Committee? = NoWritten Agreement? = Yes Schedule L, Part 2, Loans To and From Interested Persons Name of Person: David Lopatofsky, MDDisqualified Person Code: Key EmployeePurpose of Loan: Educational AssistanceOriginal Amount: $43,757Balance Due: $39,274Loan in Default? = NoApproved by Board or Committee? = NoWritten Agreement? = Yes 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 UPMC 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. The Williamsport Hospital 777 Rural Avenue Williamsport PA 17701 240795508 Hospital PA 501 (c) (3) Line 3 UPMC Susquehanna 0 Divine Providence Hospital 1100 Grampian Blvd Williamsport PA 17701 240799343 Hospital PA 501 (c) (3) Line 3 UPMC Susquehanna 0 Muncy Valley Hospital 215 East Water Street Muncy PA 17756 240806023 hospital PA 501 (c) (3) Line 3 UPMC Susquehanna 0 Susquehanna Health Foundation 1100 Grampian Blvd Williamsport PA 17701 232743470 Fundraising and affiliated activities PA 501 (c) (3) Line 11a, I 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 Williamsport Area Ambulance Service Cooperative 700 High Street Williamsport PA 17701 232416166 Ambulance Transports PA 501 (c) (3) Line 9 N/A 0 Soliders & Sailors Memorial Hospital 32-36 Central Avenue Wellsboro PA 16901 232176963 Hospital PA 501 (c) (3) Line 3 UPMC Susquehanna 0 The Green Home 37 Central Ave Wellsboro PA 16901 240804365 Skilled nursing & assisted living PA 501 (c) (3) Line 9 UPMC Susquehanna 0 Tioga Health Care Partners 15 Meade Street Wellsboro PA 16901 251765538 Physician Services PA 501 (c) (3) Line 11b, II UPMC Susquehanna 0 Laurel Management Services 15 Meade Street Wellsboro PA 16901 251644910 Mgmt consulting & supervisory services PA 501 (c) (3) Line 11b, II UPMC Susquehanna 0 Laurel Realty 15 Meade Street wellsboro PA 16901 231403678 Own & manage real estate PA 501 (c) (2) N/A UPMC Susquehanna 0 Laurel Health System 15 Meade Street Wellsboro PA 16901 240795488 Coordinate & manage the delivery of healthcare PA 501 (c) (3) Line 11b, II UPMC Susquehanna 0 Laurel Health Foundation 15 Meade Street Wellsboro PA 16901 251810488 Fundraising and affiliated activities PA 501 (c) (3) Line 11a, I Laurel Health System 0 Susquehanna Health Innovation Center Inc 700 High Street 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 Susquehanna Ventures 1201 Grampian Blvd Williamsport PA 17701 232470263 Pharmacy and infusion services PA UPMC Susquehanna C 0 Susquehanna Health System Insurance Network LTD PO Box 1159 Grand Caymans CJ KY1-1102 980458722 Captive insurance company CJ UPMC Susquehanna 0 Tyoga Carenet 15 Meade Street Wellsboro PA 16901 251810967 Integrate Health Care PA UPMC Susquehanna C 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 0 0 0 0