2017-02-14T15:59:33-06:00 2016-06-30 430352985 KERBER ECK & BRAECKEL LLP 1116 W MAIN ST CARBONDALE IL 629012335 990 2015-07-01 370661202 FAIRFIELD MEMORIAL HOSPITAL ASSOC FAIR 6188422611 303 NW 11TH STRT FAIRFIELD IL 62837 KATHERINE BUNTING CEO 6188422611 2017-02-10 true ANNA GUETERSLOH P01315485 6185291040 2017-02-14 2015 2017-02-10 21:41:12Z KATHERINE BUNTING 303 NW 11TH ST FAIRFIELD IL 62837 28865803 false X WWW.FAIRFIELDMEMORIAL.ORG X 1943 IL THE MISSION OF FAIRFIELD MEMORIAL HOSPITAL IS TO MAINTAIN AND IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. 9 7 356 53 0 554388 264072 27127241 27788161 31240 179090 808385 634480 28521254 28865803 0 0 13584090 14691476 0 0 14079425 14316653 27663515 29008129 857739 -142326 25680755 25775734 10857590 11025865 14823165 14749869 X THE MISSION OF FAIRFIELD MEMORIAL HOSPITAL IS TO MAINTAIN AND IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. false false 29008129 28601731 AS A NOT-FOR-PROFIT COMMUNITY HOSPITAL, FAIRFIELD MEMORIAL HOSPITAL IS A CHARITABLE ORGANIZATION THAT EXISTS TO ADVANCE THE HEALTH OF THE RESIDENTS OF WAYNE COUNTY AND SURROUNDING COMMUNITIES. FAIRFIELD MEMORIAL HOSPITAL OPERATES A RURAL HEALTHCARE FACILITY WITH 25 ACUTE CARE BEDS AND 30 SKILLED CARE BEDS. IN AUGUST 2008 THE HOPSITAL OPENED AN OUTPATIENT PHYSICIAN CLINIC. FAIRFIELD MEMORIAL HOSPITAL PROVIDES QUALITY MEDICAL HEALTHCARE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORGIN, HANDICAP, AGE OR ABILITY TO PAY. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION AND STABILITY OF FAIFIELD MEMORIAL HOSPITAL, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE ESSENTIAL MEDICAL SERVICES. THEREFORE, IN KEEPING WITH THIS CORPORATION'S COMMITMENT TO SERVE ALL MEMBERS OF THE COMMUNITY, FREE CARE AND/OR SUBSIDIZED CARE,CARE PROVIDED TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS AT BELOW COST,AND HEALTH ACTIVITIES AND PROGRAMS TO SUPPORT THE COMMUNITY WILL BE CONSIDERED WHERE THE NEED AND/OR INDIVIDUALS INABILITY TO PAY COEXISTS. THE COMMUNITY BENEFITS CAN BE MEASURED IN MANY WAYS INCLUDING: DIRECT PATIENT CARE, SCREENINGS, EDUCATION, FUNDRAISING, AND COMMUNITY SERVICE EFFORTS OF OUR COLLEAGUES. THE HOSPITAL PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS, PROVIDING SERVICES TO BOTH MEDICARE AND MEDICAID PATIENTS. CHARITY CARE IS ALSO PROVIDED THROUGH THE HOSPITAL'S INTERNAL POLICY. 29008129 true true false false false false false false false false true false false false true true true false false false false false false false false false true true false false true false false false true false false true false false false false false false true false false false true 25 0 356 true false false false false false false false false false false X 9 7 false false false false false false false true true false false true true true true true true true true false IL X AMY MARSH 6188478260 303 NW 11TH ST FAIRFIELD IL 62837 PATRICK MOLT MD PRESIDENT 10.00 X 59088 0 0 MARTY HEFLIN TREASURER 5.00 X 0 0 0 JAMIE POLLARD TRUSTEE 1.00 X 0 0 0 ANITA POND TRUSTEE 1.00 X 0 0 0 SANDY SIMPSON TRUSTEE 1.00 X 0 0 0 DONNA SULLIVAN TRUSTEE 4.00 X 0 0 0 JOSEPH HUNGERFORD VICE PRESIDE 2.00 X 0 0 0 DOUG WILSON TRUSTEE 1.00 X 0 0 0 JARED VAUGHN TRUSTEE 4.00 X 0 0 0 KATHERINE BUNTING CEO 40.00 X 245742 0 8319 ANN IGNAS CNO 40.00 X 113445 0 7101 MELODY MORGAN CFO 40.00 X 89760 0 14392 WESLEY THOMPSON PHYSICIAN 40.00 X 377746 0 18094 CHRIS BALLARD PHYSICIAN 40.00 X 289535 0 16566 KYLE KAKAC PHYSCIAN 40.00 X 270671 0 18030 ALEXIS KING CRNA 40.00 X 199538 0 15594 KIMBERLY KING CRNA 40.00 X 197773 0 16681 1843298 114777 11 false true false MURRAY COMPANY 1215 FERN RIDGE PKWY SUITE 213 ST LOUIS MO 63141 CAFETERIA 461061 ARAMARK UNIFORM SERVICES 25259 NETWORK PLACE CHICAGO IL 60673 LAUNDRY 443075 DR RODNEY BEELER 2142 KETTLES HILL COURT EVANSVILLE IN 477258266 ER PHYSICIAN 335788 MICHELLE O'NEILL 10345 WILMINGTON DRIVE EVANSVILLE IN 47577 ER PHYSICIAN 331830 JAMES GRUBER 2025 ST MEINRAD RD ST MEINRAD IN 47577 ER PHYSICIAN 291110 17 44816 1255 218001 264072 NET PATIENT SERVICE REVENUE 27788161 27788161 27788161 179090 179090 227724 227724 227724 227724 MEDICARE EHR REVENUE 197971 197971 CAFETERIA SERVICES 174507 174507 MISCELLANEOUS 22540 22540 11738 11738 406756 28865803 28601731 X 508035 508035 11330439 11330439 138737 138737 1925433 1925433 788832 788832 3794 3794 35700 35700 4926005 4926005 96054 96054 1605256 1605256 1153143 1153143 186259 186259 338047 338047 1484828 1484828 343636 343636 DRUGS 1225255 1225255 MEDICAL SUPPLIES 1155233 1155233 REPAIRS AND MAINTENANCE 581575 581575 BED AND PROVIDER TAX AMT 573999 573999 607869 607869 29008129 29008129 0 0 1744 1744 2101457 1977693 5442175 5891771 167484 114004 778302 904508 323720 376118 285501 769350 37901058 22802629 15953499 15098429 800 800 626073 641317 25680755 25775734 2446397 3065062 708759 511896 7135031 6614592 270181 519315 297222 315000 10857590 11025865 X 14502030 14359704 320566 389596 569 569 14823165 14749869 25680755 25775734 -142326 69030 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 449428 449428 20213795 9246336 10967459 17010267 13518584 3491683 227568 37709 189859 15098429 THIRD PARTY REIMBURSEMENT PROGRAMS 315000 315000 X 28934833 69030 69030 28865803 28865803 29008129 29008129 29008129 SCHEDULE D, PAGE 3, PART X THERE WERE NO PENALTIES, INTEREST, OR UNCERTAIN TAX BENEFITS IDENTIFIED AND RECORDED AS A LIABILITY. SCHEDULE D, PAGE 4, PART XI, LINE 2D CHANGE IN TEMPORARILY RESTRICTED ASSETS 69,030 true true true X true X true true false false 1921254 573999 1347255 0.04640 1921254 573999 1347255 0.04640 37745 37745 0.00130 37745 37745 0.00130 1958999 573999 1385000 0.04770 true 1241912 310478 13327341 14893552 -1566211 X true true 1 1 FAIRFIELD MEMORIAL HOSPITAL 303 NW 11TH ST FAIRFIELD IL 62837 WWW.FAIRFIELDMEMORIAL.ORG 320005545 X X X X FAIRFIELD MEMORIAL HOSPITAL 1 false false true X X X X X X X X X X 16 true false false true X WWW.FAIRFIELDMEMORIAL.ORG X true 16 true WWW.FAIRFIELDMEMORIAL.ORG false false true X 200.000000000000 300.000000000000 X X X true true X X X X true X WWWFAIRFIELDMEMORIALORG X X X X X X true X X true X X X X X X true X false false FACILITY 1, FAIRFIELD MEMORIAL HOSPITAL - PART V, LINE 5 THE HOSPITAL TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITY SERVED BY THE HOSPITAL, INCLUDING THOSE WITH SPECIAL KNOWLEDGE OF, OR EXPERTISE IN PUBLIC HEALTH (LOCAL, REGIONAL, STATE AND/OR TRIBAL). MEMBERS OF MEDICALLY UNDERSERVED, LOW-INCOME, AND MINORITY POPULATIONS SERVED BY THE HOSPITAL OR INDIVIDUALS OR ORGANIZATIONS REPRESENTING THE INTERESTS OF SUCH POPULATIONS ALSO PROVIDED INPUT. THE MEDICALLY UNDERSERVED ARE MEMBERS OF A POPULATION WHO EXPERIENCE HEALTH DISPARITIES, ARE AT-RISK OF NOT RECEIVING ADEQUATE MEDICAL CARE AS A RESULT OF BEING UNINSURED OR UNDERINSURED, AND/OR EXPERIENCING BARRIERS TO HEALTHCARE DUE TO SOCIOECONOMIC FACTORS SUCH AS GEOGRAPHIC, LANGUAGE, FINANCIAL, ETC. MEMBERS OF THE CHNA STEERING COMMITTEE, THOSE WHO BOTH PARTICIPATED IN FOCUS GROUPS AND THE NEEDS IDENTIFICATION AND PRIORITIZATION PROCESS, WERE CHOSEN BASED ON THEIR UNIQUE EXPERTISE AND EXPERIENCE, INFORMED PERSPECTIVES, AND INVOLVEMENT WITH THE COMMUNITY. THE CHNA STEERING COMMITTEE MEMBERS INCLUDED: CHNA STEERING COMMITTEE MEMBER AREAS OF EXPERTISE: -DIRECTOR, WAYNE COUNTY HEALTH DEPARTMENT -DIRECTOR, THERAPY SERVICES, FAIRFIELD MEMORIAL HOSPITAL -PHARMACIST, FAIRFIELD MEMORIAL HOSPITAL -CEO, FAIRFIELD MEMORIAL HOSPITAL OTHERS PROVIDING INPUT INCLUDED THROUGH THE FOCUS GROUPS INCLUDED: -LOCAL SCHOOL ADMINISTRATOR -SHERIFF, WAYNE COUNTY -BOARD MEMBER, HOUSING AUTHORITY -LOCAL SURGEON -ADMINISTRATOR, WAY-FAIR REHAB FACILITY 1, FAIRFIELD MEMORIAL HOSPITAL - PART V, LINE 11 PROCESS BY WHICH NEEDS WILL BE ADDRESSED: 1. MENTAL HEALTH THE GROUP IDENTIFIED ACCESS TO CARE ISSUES FOR PERSONS OF ALL AGES WITH BEHAVIORAL HEALTHCARE NEEDS. THE AREA IS EXPERIENCING A SHORTAGE OF PSYCHIATRISTS AND COUNSELORS WHICH IS IMPACTING ALL POTENTIAL PATIENTS AND PARTICULARLY, MEDICAID PATIENTS AND YOUTH. THE FINDINGS REFLECTED THE FOCUS GROUPS CONCERNS OF IDENTIFICATION OF THE NEED FOR COUNSELING FOR YOUTH ON ISSUES OF ANGER MANAGEMENT AND FAMILY ISSUES AND THE NEED TO ADDRESS STRESS AND RELATED ISSUES FOR THOSE FACING FINANCIAL CHANGE AND CHALLENGES. THE GROUP ALSO IDENTIFIED THE NEED FOR INCREASED LOCAL SUBSTANCE ABUSE PREVENTION AND ACCESS TO SERVICES FOR REHABILITATION AND RECOVERY. ACTIONS THE HOSPITAL INTENDS TO TAKE TO ADDRESS THE HEALTH NEED: EXPLORE A SECOND FULL TIME MENTAL HEALTH COUNSELOR PARTNER WITH LOCAL COURTS TO CREATE A STRATEGIC REFERRAL PROGRAM WITHOUT REGARD TO ABILITY TO PAY DEVELOP TELE-HEALTH FOR PSYCHIATRY DEVELOP TELE-HEALTH PHARMACY FOR CONSULTATION WITH MENTAL HEALTH MEDICATION SUB-SPECIALTIES EDUCATE THE COMMUNITY ABOUT MENTAL HEALTH ISSUES AND AVAILABLE MENTAL HEALTH SERVICES FOR ALL AGES DEVELOP LUNCHTIME GRAB-AND-GO PROGRAMS FOR PSYCH-EDUCATION ON TOPICS OF LOCAL INTEREST FOR YOUTH AND ADULTS, INCLUDING STRESS AND ANGER MANAGEMENT DEVELOP ONE MEANS OF MEASURING NEW PERSONS REACHED WITH SERVICES. ANTICIPATED IMPACT OF THESE ACTIONS: INCREASED ACCESS TO MENTAL HEALTH SERVICES FOR ALL AGES AND INCOME LEVELS REDUCED STRESS IMPROVED COPING MECHANISMS THAT MAY IMPACT SUBSTANCE ABUSE, ACTING OUT, AND OTHER ISSUES PROGRAMS AND RESOURCES THE HOSPITAL PLANS TO COMMIT TO ADDRESS THE HEALTH NEED: ADMINISTRATION DIRECTOR OF THERAPY SERVICES DIRECTOR OF PHYSICIAN SERVICES PLANNED COLLABORATION BETWEEN THE HOSPITAL AND OTHER FACILITIES OR ORGANIZATIONS: SCHOOLS COURTS DEPARTMENT OF CHILDREN AND FAMILY SERVICES FOSTER CARE COUNTY HEALTH DEPARTMENT SHERIFF 2. WELLNESS THE GROUP IDENTIFIED RELATED NEEDS AROUND HEART DISEASE AND DIABETES AND THE UNDERLYING ISSUES OF OBESITY AND NUTRITION AND CATEGORIZED THEM AS WELLNESS NEEDS. IT WAS FELT THAT THERE WAS A NEED FOR INCREASED EDUCATION IN ALL OF THESE AREAS ALONG WITH OPPORTUNITIES FOR RECREATION, EXERCISE, AND HEALTHY FOODS AND LIFESTYLES. SPECIFIC NEEDS WERE SEEN AS ADDRESSING NUTRITION NEEDS FOR YOUTH AND DEVELOPING OPPORTUNITIES FOR RECREATION AND PHYSICAL ACTIVITY. THE GROUP ALSO SAW A NEED FOR TARGETED ADVOCACY TO MAKE EDUCATION, SCREENINGS, AND OTHER RESOURCES AVAILABLE TO SEGMENTS OF THE POPULATION WHERE THEY ARE NEEDED MOST. FINALLY, THE GROUP IDENTIFIED A NEED FOR BETTER ACCESS TO PRIMARY CARE FOR UNDERINSURED AND UNINSURED. ACTIONS THE HOSPITAL INTENDS TO TAKE TO ADDRESS THE HEALTH NEED: CONTINUE THE NEW CARE COORDINATION PROGRAM FOR MEDICARE FOR ENCOURAGEMENT OF PHYSICAL ACTIVITY PARTNER WITH KINGDOM KIDS TO PROVIDE DIETARY EDUCATION TO FAMILIES AND FUNDS TO SUPPORT HEALTHY MEALS AND FOOD FOR YOUTH CONTINUE PARTNERSHIP WITH KIDS IN MOTION PROGRAM CONTINUE AND EXPAND HEALTH FAIRS FOR SCREENINGS EXPAND PERIODIC REDUCED-COST LAB TESTS, INCLUDING FREE MAMMOGRAPHY AND COLON SCREENINGS DEVELOP EDUCATION PROGRAM ABOUT CHRONIC ILLNESS AND THE NEED FOR PHYSICAL ACTIVITY, HEALTHY DIETS, AND SCREENINGS CONTINUE CORPORATE HEALTH AND SAFETY EDUCATION AND HEALTH SCREENING PROGRAMS PLANNED COLLABORATION BETWEEN THE HOSPITAL AND OTHER FACILITIES OR ORGANIZATIONS: KINGDOM KIDS KIDS IN MOTION 3. CANCER THE STEERING COMMITTEE IDENTIFIED ISSUES SURROUNDING CANCER AS A SIGNIFICANT LOCAL HEALTH NEED. THE GROUP NOTED HIGH LEVELS OF CANCER GENERALLY IN, AND SURROUNDING, THE SERVICE AREA AND EXPRESSED CONCERN OVER BOTH THE CAUSES OF THE HIGH RATES AND THE AVAILABILITY AND USE OF SERVICES TO ADDRESS CANCER. THE GROUP SAW SPECIFIC NEEDS TO: ATTEMPT TO IDENTIFY THE CAUSES OF CANCER LOCALLY TO PROVIDE INFORMATION ABOUT CANCER AND CANCER PREVENTION, AND SCREENINGS TO THE COMMUNITY ACTIONS THE HOSPITAL INTENDS TO TAKE TO ADDRESS THE HEALTH NEED: START A CANCER SUPPORT GROUP FOR PATIENTS, FAMILY, AND OTHER CAREGIVERS DEVELOP AND PRESENT EDUCATION ABOUT LOCAL CANCER SERVICES ATTEMPT TO EXPAND LOCAL AVAILABILITY OF SERVICES FROM CANCER SPECIALISTS CONTINUE AND EXPAND ACCESS TO SCREENINGS INCLUDING MAMMOGRAPHY, PROSTATE SCREENING, AND COLON SCREENING WHILE FAIRFIELD MEMORIAL HOSPITAL IS NOT POSITIONED TO UNDERTAKE THE RESEARCH NECESSARY TO ATTEMPT TO IDENTIFY THE CAUSES OF CANCER LOCALLY, THE HOSPITAL WILL ATTEMPT TO PARTNER WITH WAYNE COUNTY HEALTH DEPARTMENT AND THE WAYNE COUNTY FARM BUREAU TO IDENTIFY APPROPRIATE RESOURCES TO ATTEMPT TO EXPLAIN THE LOCAL CANCER RATES ANTICIPATED IMPACT OF THESE ACTIONS: EXPANDED SCREENINGS ARE EXPECTED TO LEAD TO EARLIER DETECTION, WHICH MAY LEAD TO DECREASED INCIDENCE OF MORTALITY DUE TO CANCER INCREASED AWARENESS OF CANCER RISKS AND THE NEED FOR SCREENING AND RISK AVOIDANCE WITH YOUNGER AUDIENCES BETTER UNDERSTANDING OF AVAILABLE LOCAL SERVICES IMPROVED PATIENT AND CAREGIVER SUPPORT TO AID IN REDUCING STRESS AND INFORMED DECISION-MAKING PROGRAMS AND RESOURCES THE HOSPITAL PLANS TO COMMIT TO ADDRESS THE HEALTH NEED: ADMINISTRATION CERTIFIED CANCER NURSE ONCOLOGISTS FAMILY PRACTICE PROVIDERS AND ANCILLARY DEPARTMENTS INCLUDING LAB, DIETITIAN, TELE-RADIOLOGY, AND ULTRASONOGRAPHERS PLANNED COLLABORATION BETWEEN THE HOSPITAL AND OTHER FACILITIES OR ORGANIZATIONS: ONCOLOGY GROUP SUSAN G. KOMEN FOUNDATION, RACE FOR THE CURE FACILITY 1, FAIRFIELD MEMORIAL HOSPITAL - PART V, LINE 16I THE POLICY IS VERBALLY DISCUSSED WITH ALL SELF-PAY PATIENTS. FACILITY 1, FAIRFIELD MEMORIAL HOSPITAL - PART V, LINE 22D IF A PATIENT APPLIES FOR FINANCIAL ASSISTANCE AND THEY ARE APPROVED THE BILL IS REDUCED TO ZERO. IF THE PATIENT QUALIFIES FOR THE PATIENT DISCOUNT ACT, THEN THE CURRENT ASSIGNED PERCENTAGE IS CHARGED. IF NEITHER APPLY, THEN THE PATIENT IS OFFERED A 20% DISCOUNT IF PAID IN FULL OR AN OFFER OF REASONABLE INTEREST FREE PAYMENTS ARE SET UP. 1 HORIZON HEALTHCARE 213 NW 10TH STREET SUITE A FAIRFIELD IL 62837 OUTPATIENT PHYSICIAN CLINIC PART I, LINE 7 - COSTING METHODOLOGY EXPLANATION THE FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION USED A COST TO CHARGE RATIO AS CALCULATED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES, INCLUDED IN THE SCHEDULE H INSTRUCTIONS TO DETERMINE THE AMOUNTS ON LINES 7A AND 7B OF PART I OF SCHEDULE H. PART III, LINE 2 - BAD DEBT EXPENSE METHODOLOGY THE HOSPITAL CALCULATED BAD DEBT EXPENSE AT COST USING THE COST TO CHARGE RATIO AS CALCULATED USING WORKSHEET 2 OF THE SCHEDULE H INSTRUCTIONS. PATIENT ACCOUNTS ARE WRITTEN OFF TO BAD DEBT ONLY AFTER ALL COLLECTION PROCEDURES HAVE BEEN EXHAUSTED AS OUTLINED IN SCHEDULE H, PART III, LINE 9B. PATIENT ACCOUNTS ARE WRITTEN OFF TO BAD DEBT AFTER ALL DISCOUNTS AND PAYMENTS HAVE BEEN APPLIED. PART III, LINE 3 BAD DEBT EXPENSE, PATIENTS ELIGIBLE FOR ASSISTANCE BASED ON THE HOSPITAL'S EXPERIENCE WITH ALL ITS PATIENTS, THEY ESTIMATE THAT IT IS LIKELY THAT UP TO ONE FOURTH OF THE PATIENT ACCOUNTS WRITTEN OFF TO BAD DEBTS MAY QUALIFY FOR CHARITY CARE OR OTHER ASSISTANCE BUT CHOSE NOT TO APPLY. THEREFORE, 25% OF THE BAD DEBT EXPENSE WAS INCLUDED ON PART III, LINE 3 AT COST. BAD DEBT EXPENSE FOOTNOTE TO FINANCIAL STATEMENTS NOTE S - UNCOMPENSATED CARE AND COMMUNITY BENEFIT IN SUPPORT OF ITS MISSION, THE HOSPITAL VOLUNTARILY PROVIDES CARE TO PATIENTS AT LESS THAN ITS ESTABLISHED CHARGES FOR PATIENTS THAT MEET THE HOSPITAL'S CHARITY CARE CRITERIA. BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED IN NET PATIENT SERVICES REVENUE. IN ADDITION, THE HOSPITAL PROVIDES SERVICES TO OTHER MEDICALLY INDIGENT PATIENTS UNDER CERTAIN GOVERNMENT-REIMBURSED PUBLIC AID PROGRAMS. SUCH PROGRAMS PAY PROVIDERS AMOUNTS WHICH ARE LESS THAN ESTABLISHED CHARGES FOR THE SERVICES PROVIDED TO THE RECIPIENTS AND MANY TIMES THE PAYMENTS ARE LESS THAN THE COST OF RENDERING THE SERVICES PROVIDED. THE HOSPITAL'S TOTAL COST OF UNCOMPENSATED CARE RELATING TO THESE SERVICES AND OTHER SERVICES ARE AS FOLLOWS: 2016 2015 CHARITY CARE - 38,910 STATE MEDICAID AND OTHER PUBLIC PROGRAMS 1,347,255 1,081,993 UNCOLLECTIBLE ACCOUNTS 1,379,616 882,248 THE UNCOMPENSATED CARE COST OF STATE MEDICAID AND OTHER PUBLIC AID PROGRAMS IS DETERMINED BY COMPUTING THE COST OF PROVIDING THAT CARE LESS AMOUNTS PAID BY THE PROGRAM. IN ADDITION TO THE ABOVE COST OF UNCOMPENSATED CARE, THE HOSPITAL ALSO COMMITS SIGNIFICANT TIME AND RESOURCES TO ENDEAVORS AND CRITICAL SERVICES WHICH MEET OTHERWISE UNFULFILLED COMMUNITY NEEDS. MANY OF THESE ACTIVITIES ARE SPONSORED WITH KNOWLEDGE THAT THEY WILL NOT BE SELF-SUPPORTING OR FINANCIALLY VIABLE. PART III, LINE 8 - MEDICARE EXPLANATION UNPAID COST OF MEDICARE REPRESENTS THE COST (DETERMINED USING THE OVERALL COST TO CHARGE RATIO) OF PROVIDING SERVICES TO PRIMARILY ELDERLY BENEFICIARIES OF THE MEDICARE PROGRAM, IN EXCESS OF PAYMENTS FOR THOSE SERVICES. IRS REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENT HEALTH BENEFTIS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THIS IMPLIES THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT. PART III, LINE 9B - COLLECTION PRACTICES EXPLANATION THE FAIRFIELD MEMORIAL HOSPITAL APPLIES ITS COLLECTION PRACTICES EQUALLY TO ALL PATIENTS, BOTH CHARITY CARE ELIGIBLE AND NON-CHARITY CARE PATIENTS. THE PROCEDURES FOR COLLECTION ON PATIENT ACCOUNTS ARE AS FOLLOWS: SELF-PAY ACCOUNTS AND ACCOUNTS WITH BALANCES AFTER INSURANCE ARE SENT A LETTER REQUESTING PAYMENT. IF NO RESPONSE IS RECEIVED WITHIN 35 DAYS, THE ACCOUNT IS TRANSFERRED TO OUR EARLY-OUT DEPARTMENT FOR A FOLLOW-UP STATEMENT/PHONE CALL TO THE PATIENT. THE HOSPITAL OFFERS THE PATIENTS SEVERAL PAYMENT ALTERNATIVES: 1. CASH/CHECK FOR THE FULL AMOUNT 2. MASTERCARD/VISA/DISCOVER 3. SHORT-TERM MONTHLY INSTALLMENTS BASED ON OUTSTANDING BALANCE SPECIAL PAYMENT ARRANGEMENTS CAN BE MADE UPON REQUEST AND COMPLETION OF A CREDIT APPLICATION WHICH WILL BE VERIFIED AND APPROVED BY THE BUSINESS OFFICE DIRECTOR. IF PAYMENT OR SATISFACTORY PAYMENT ARRANGMENTS AS OUTLINED ABOVE ARE NOT MADE, THE ACCOUNT WILL PROCEED THROUGH A COLLECTION PROCESS AS FOLLOWS: DAY 1 - 1ST NOTICE SENT DAY 7-14 - FIRST PHONE CALL IS MADE. AT LEAST ONE PHONE CALL OR NOTICE PER WEEK FOR THE REMAINDER OF THE EARLY-OUT 90 DAY PERIOD DAY 75 - DEMAND NOTICE IS SENT DAY 90 - ACCOUNT IS SENT TO COLLECTIONS ANY ACCOUNT THAT IS SENT TO COLLECTIONS MAY BE TURNED OVER TO AN ATTORNEY AND ANY ADDITIONAL COSTS ASSOCIATED WITH COLLECTIONS WILL BE ADDED TO THE ACCOUNT BALANCE. PART VI, LINE 2 - NEEDS ASSESSMENT GENERALLY SPEAKING, THE DETERMINATION OF CURRENT AND FUTURE HEALTH CARE NEEDS OF THE COMMUNITY OR COMMUNITIES SERVED BY FAIRFIELD MEMORIAL HOSPITAL IS BASED ON ALL OR A COMBINATION OF THE FOLLOWING FACTORS; EXISTENCE OR NONEXISTENCE OF SERVICES, OPPORTUNITY, SUPPLY, DEMONSTRATED NEED, "VOICE OF THE CUSTOMER", AND /OR COLLABORATIVE EFFORTS WITH OUTSIDE ENTITIES, GOVERMENT AGENCIES, AND OTHER HEALTH CARE PROVIDERS THAT WOULD ENABLE THE FILLING OF A NEED OR ENHANCE AND COMPLIMENT AN ALREADY EXISTING SERVICE. DATA IS GATHERED CONSTANTLY THROUGH BENCHMARKETING, MARKET RESEARCH, CUSTOMER SURVEYS, PHYSCIAN INPUT, AND THROUGH CONSTANT MONITORING OF STATE AND FEDERAL GUIDELINES. THIS INFORMATION IS REVIEWED AND ANALYZED BY THE HOSPITAL'S SENIOR LEADERSHIP AND INCORPORATED INTO STRATEGIC PLANNING PROCESSES. PART VI, LINE 3 - PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE SIGNS ARE POSTED IN THE FACILITY. THE PATIENT'S BILL INFORMS THEM OF FINANCIAL ASSISTANCE PROGRAM. OUR HOSPITAL WEBSITE HAS A LINK TO THE FINANCIAL ASSISTANCE APPLICATION. SOCIAL SERVICE DEPARTMENT SPEAKS TO INPATIENTS ABOUT THE PROGRAM. PART VI, LINE 4 - COMMUNITY INFORMATION FAIRFIELD MEMORIAL HOSPITAL SERVES THE POPULATIONS OF WAYNE COUNTY AND THE SURROUNDING COMMUNITIES WITHOUT REGARD TO AGE, GENDER, INCOME , ETHIC ORGIN, INSURANCE COVERAGE, OR ABILITY TO PAY. WAYNE COUNTY IS A RURAL AREA WITH AN ESTIMATED POPULATION OF 16,423. THE MEDIAN HOUSEHOLD INCOME IN 2015 WAS 44,993, WHICH WAS 83% OF ILLINOIS' AVERAGE. THE PERCENTAGE OF INDIVIDUALS BELOW POVERTY LEVEL WAS 12.8%. PART VI, LINE 7 - STATE FILING OF COMMUNITY BENEFIT REPORT ILLINOIS X X X X X false false false false false false false false false KATHERINE BUNTING CEO 245742 4769 3550 254061 WESLEY THOMPSON PHYSICIAN 377746 7120 10974 395840 CHRIS BALLARD PHYSICIAN 289535 5560 11006 306101 KYLE KAKAC PHYSCIAN 270671 5331 12699 288701 ALEXIS KING CRNA 199538 3905 11689 215132 KIMBERLY KING CRNA 197773 3900 12781 214454 NICOLE FYIE PHYSICIAN WIFE OF BOARD MEMBER MEDICAL SCHOOL LOAN X 267400 114004 false true true 114004 PATRICK MOLT PHYSICIAN 59088 BOARD MEMBER false NICOLE FYIE PHYSICIAN 267535 WIFE OF BOARD MEMBER false FORM 990, PAGE 1, PART I, LINE 6 VOLUNTEERS ARE PART OF THE HOSPITAL AUXILIARY WHO RUN FUNDRAISERS ON BEHALF OF THE HOSPITAL AND OPERATE THE GIFT SHOP. FORM 990, PAGE 2, PART III, LINE 4A COMMITMENT TO SERVE ALL MEMBERS OF THE COMMUNITY, FREE CARE AND/OR SUBSIDIZED CARE,CARE PROVIDED TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS AT BELOW COST,AND HEALTH ACTIVITIES AND PROGRAMS TO SUPPORT THE COMMUNITY WILL BE CONSIDERED WHERE THE NEED AND/OR INDIVIDUALS INABILITY TO PAY COEXISTS. THE COMMUNITY BENEFITS CAN BE MEASURED IN MANY WAYS INCLUDING: DIRECT PATIENT CARE, SCREENINGS, EDUCATION, FUNDRAISING, AND COMMUNITY SERVICE EFFORTS OF OUR COLLEAGUES. THE HOSPITAL PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS, PROVIDING SERVICES TO BOTH MEDICARE AND MEDICAID PATIENTS. CHARITY CARE IS ALSO PROVIDED THROUGH THE HOSPITAL'S INTERNAL POLICY. FORM 990, PAGE 6, PART VI, LINE 11B THE FORM 990 WAS REVIEWED BY THE CFO AND FINANCE COMMITTEE. AFTER THE FINANCE COMMITTEE IT WAS TAKEN TO THE FULL BOARD FOR APPROVAL. FORM 990, PAGE 6, PART VI, LINE 12C ANNUALLY EACH BOARD MEMBER RECEIVES THE CORPORATE COMPLIANCE POLICY WHICH INCLUDES THE CONFLICT OF INTEREST POLICY WITHIN IT TO REVIEW AND SIGN THAT THEY HAVE READ THE POLICY AND HAVE NO COMFLICTS. ALL SIGNED DOCUMENTS ARE KEPT ON FILE IN ADMINISTRATION OFFICE. FORM 990, PAGE 6, PART VI, LINE 15A THE CEO'S COMPENSATION PROCESS INVOLVES ALLIANT, THE HOSPITAL'S MANAGEMENT COMPANY, BRINGING EVALUATION TIME SALARY INFORMATION FOR OTHER ALLIANT HOSPITALS WHICH INCLUDE HOSPITAL'S IN THE FOLLOWING STATES: ILLINOIS, KENTUCKY, AND INDIANIA; AS WELL AS SALARY INFORMATION FOR CEO'S FROM OTHER HOSPITAL'S IN RELEVANT SIZE (IN REVENUES) TO FMH. THE SALARY COMPARISON INFORMATION IS PRESENTED TO THE PERSONNEL COMMITTEE OF THE BOARD IN WHICH THEY REVIEW THE INFORMATION AND ESTABLISH THE RATE FOR THE CEO. FORM 990, PAGE 6, PART VI, LINE 15B MARKET WAGE DATA FOR THE HEALTHCARE INDUSTRY IS REVIEWED FOR COMPARABLE RATES FROM THREE SALARY SURVEYS INCLUDING ALLIANT AS ONE. THE CEO DETERMINES THE AMOUNTS FOR THE OFFICERS. FORM 990, PAGE 6, PART VI, LINE 19 COPIES OF THE ORGANIZATIONS GOVERING DOCUMENTS, CONFLICT OF INTEREST POLICIES, FINANCIAL STATEMENTS, AND THE FEDERAL FORM 990 TAX RETURN ARE AVAILABLE UPON REQUEST FROM THE ADMINISTRATIVE OFFICES. FORM 990, PART IX, LINE 11G PROFESSIONAL SERVICES 3,246,460 0 0 PHYSICIANS FEES 1,679,545 0 0 FORM 990, PART XI, LINE 9 CHANGE IN TEMPORARILY RESTRICTED 69,030 TOTAL 69,030 FAIRFIELD MEMORIAL HOSPITAL FOUNDAT 303 NW 11TH STREET FAIRFIELD IL 62837 371185754 SUPPORT IL 501C3 11B N/A false false false true false false false false false false false false false false false false false false false false FMH FOUNDATION C ACTUAL CASH RECEIVED