2016-04-15T07:46:38-05:00 2015-06-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2014-07-01 561479712 CAROMONT MEDICAL GROUP INC CARO 7048342000 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 280531747 SIGNING OFFICER EVP, CFO 7048342000 2016-03-25 1 AMY BIBBY P00445891 8282542254 2014 2016-08-17 19:52:53Z DAVID O'CONNOR 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 280531747 119223148 0 X WWW.CAROMONT.ORG X 1985 NC TO PROVIDE EXCEPTIONAL HEALTH CARE TO THE COMMUNITIES WE SERVE. 3 1 820 0 0 0 0 0 92461244 101328540 3718649 2214676 3068263 2760180 99248156 106303396 0 2150 0 0 79780100 89058793 0 0 0 31993979 28003996 111774079 117064939 -12525923 -10761543 65089441 51866461 10029156 8686929 55060285 43179532 X TO PROVIDE EXCEPTIONAL HEALTH CARE TO THE COMMUNITIES WE SERVE. 0 0 111998632 2150 101328540 SEE SCHEDULE O.CAROMONT MEDICAL GROUP OWNS AND OPERATES A NETWORK OF OVER 40 PRIMARY CARE AND SPECIALTY PHYSICIAN PRACTICES AND TWO URGENT CARE CENTERS. IT EMPLOYS OVER 200 PHYSICIANS AND OVER 70 ADVANCED PRACTITIONERS IN TWENTY-FOUR DIFFERENT SPECIALTIES. IN FISCAL YEAR 2015, THE MEDICAL GROUP PROVIDED OVER 532,000 PATIENT VISITS. CAROMONT MEDICAL GROUP IS COMMITTED TO PROVIDING HIGH QUALITY CARE TO ITS PATIENTS. 100% OF ITS PRIMARY CARE PRACTICES HAVE BEEN RECOGNIZED AS A LEVEL 3 PATIENT-CENTERED MEDICAL HOME. THIS HIGHEST LEVEL OF RECOGNITION AVAILABLE TO PRIMARY CARE PRACTICES BY THE NATIONAL CENTER FOR QUALITY ASSURANCE (NCQA) IDENTIFIES PRACTICES THAT EMPHASIZE CARE COORDINATION AND COMMUNICATION TO IMPROVE QUALITY OUTCOMES FOR THEIR PATIENTS.CAROMONT MEDICAL GROUP IS ACTIVE IN ITS COMMUNITIES IN A NUMBER OF WAYS. THE PRACTICES MAKE MONETARY AND IN-KIND CONTRIBUTIONS TO COMMUNITY NON-PROFIT ORGANIZATIONS, PHYSICIANS AND STAFF VOLUNTEER AT COMMUNITY EVENTS AND HEALTH FAIRS, AND LEADERS SERVE ON COMMUNITY BOARDS. CAROMONT MEDICAL GROUP ALSO INVESTS IN THE FUTURE OF HEALTH CARE BY OFFERING OPPORTUNITIES TO ADVANCE THE EDUCATION OF LOCAL HEALTH CARE STUDENTS THROUGH PRECEPTORSHIP PROGRAMS FOR COLLEGE STUDENTS, JOB SHADOWING PROGRAMS FOR HIGH SCHOOL STUDENTS, AND MENTORSHIP PROGRAMS. 111998632 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 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 1 1 0 0 0 1 X 222 0 1 820 1 0 0 0 0 0 0 0 0 0 0 X 3 1 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X DAVID O'CONNOR 7048342000 2525 COURT DRIVE GASTONIA NC 28054 MR DONNIE LOFTIS CHAIRMAN 2015 1.00 1.00 X X 0 0 0 MRSPURGEON MACKIE CHAIRMAN 2014 1.00 1.00 X X 0 0 0 SHEILA REILLY PHD DIRECTOR 1.00 1.00 X 0 0 0 MR BARRY M POMEROY DIRECTOR 1.00 1.00 X 0 0 0 MR J CHRISTOPHER HOWELL DIRECTOR 1.00 1.00 X 0 0 0 DOUG LUCKETT CEO/PRESIDENT 1.00 49.00 X 0 857315 171735 DAVID O'CONNOR EVP/CFO/ASST. TREASURER 1.00 49.00 X 0 504341 103800 MARIA LONG EVP CHIEF LEGAL OFFICER/ASST. SECRETARY 1.00 49.00 X 0 418701 78558 DR MICHAEL R TAMBERELLA PHYSCIAN 40.00 X 784778 0 33570 DR OMER L SHEDD PHYSCIAN 40.00 X 759886 0 29432 DR DUSTIN P LETTS PHYSCIAN 40.00 X 860436 0 30670 DR JAMES P GREELISH PHYSCIAN 40.00 X 934029 0 30027 DR ALEC AKBAROV PHYSCIAN 40.00 X 779944 0 21725 RANDALL L KELLEY FORMER OFFICER 0.00 0.00 X 0 648281 0 4119073 2428638 499517 147 1 1 0 ATHENA HEALTH INC 311 ARSENAL STREET WATERTOWN MA 02472 SOFTWARE APPLICATIONS 4459473 OPTIMED HOSPITALISTS PLLC 557 BROOKDALE DR STATESVILLE NC 28677 PHYSICIAN STAFFING 2251765 AJAYKUMAR N PATEL 16529 SILVERSWORD DR CHARLOTTE NC 28213 PHYSICIAN STAFFING 527100 MEDICUS CONSULTING SERVICES LLC 7 INDUSTRIAL WAY SALEM NH 03079 PHYSICIAN STAFFING 453390 WEATHERBY LOCUMS INC 5003 SOUTH MIAMI BLVD DURHAM NC 27703 PHYSICIAN STAFFING 412389 21 PATIENT SERVICE 621400 101328540 101328540 101328540 658129 658129 14476299 12356572 563180 2119727 -563180 1556547 1556547 MISCELLANEOUS 621400 1051432 1051432 COORDINATION REVENUE 900099 925565 925565 MEANINGFUL USE 900099 743154 743154 40029 40029 2760180 106303396 101328540 0 4974856 2150 2150 76381898 72837399 3544499 2560118 2353139 206979 6314323 5738300 576023 3802454 3609284 193170 1062383 1049048 13335 44777 42752 2025 2673304 2611145 62159 6123171 5882636 240535 61591 37581 24010 3 3 1375510 1182573 192937 1647060 1636480 10580 MEDICAL SUPPLIES 10581294 10581239 55 BAD DEBT 4279097 4279097 BIOMED 155806 155806 117064939 111998632 5066307 0 1320286 1062689 7258071 6611942 710954 924778 189294 314370 18390398 8058325 13139644 10332073 38398441 28814397 3448153 3448153 624598 358059 65089441 51866461 10029156 8686929 10029156 8686929 X 55060285 43179532 55060285 43179532 65089441 51866461 -10761543 -1119210 0 X X 0 1 X 1 0 X 25293 25293 74250177 88855499 87106169 92461244 101328540 444001629 655676 1161305 2333958 3068263 2760180 9979382 74905853 90016804 89465420 95529507 104088720 454006304 0 0 0 454006304 1701412 1457535 1435414 781626 658129 6034116 1701412 1457535 1435414 781626 658129 6034116 76607265 91474339 90900834 96311133 104746849 460040420 0.98690 0.98420 0.01310 0.01580 X 1443480 1443480 7636299 1482241 6154058 219065 34679 184386 9091554 6541405 2550149 10332073 X 100865060 -1119210 -4279097 -5398307 106263367 40029 40029 106303396 112745813 -40029 -40029 112785842 4279097 4279097 117064939 PART X, LINE 2: THE SYSTEM IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE SYSTEM HAS DETERMINED THAT IT DOES NOT HAVE ANY UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF JUNE 30, 2015 AND 2014, RESPECTIVELY. FISCAL YEARS ENDING ON OR AFTER JUNE 30, 2012 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT -4,279,097. PART XI, LINE 4B - OTHER ADJUSTMENTS: MANAGEMENT FEES NET WITH EXPENSES 40,029. PART XII, LINE 2D - OTHER ADJUSTMENTS: MANAGEMENT FEES NET WITH EXPENSES -40,029. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT 4,279,097. 1 1 0 0 0 1 1 0 0 DOUG LUCKETT CEO/PRESIDENT 0 606383 0 250230 0 702 0 154427 0 17308 0 1029050 0 0 DAVID O'CONNOR EVP/CFO/ASST. TREASURER 0 384792 0 118632 0 917 0 87558 0 16242 0 608141 0 0 MARIA LONG EVP CHIEF LEGAL OFFICER/ASST. SECRET 0 319988 0 98155 0 558 0 76460 0 2098 0 497259 0 0 DR MICHAEL R TAMBERELLA PHYSCIAN 591871 0 192907 0 0 0 16336 0 17234 0 818348 0 0 0 DR OMER L SHEDD PHYSCIAN 560962 0 198924 0 0 0 12350 0 17082 0 789318 0 0 0 DR DUSTIN P LETTS PHYSCIAN 589371 0 271065 0 0 0 13436 0 17234 0 891106 0 0 0 DR JAMES P GREELISH PHYSCIAN 814799 0 119230 0 0 0 11700 0 18327 0 964056 0 0 0 DR ALEC AKBAROV PHYSCIAN 710968 0 68976 0 0 0 3900 0 17825 0 801669 0 0 0 RANDALL L KELLEY FORMER OFFICER 0 0 0 0 0 648281 0 0 0 0 0 648281 0 0 PART I, LINE 3 COMPENSATION PAID TO OFFICERS OF CAROMONT MEDICAL GROUP, INC. WAS PAID BY CAROMONT REGIONAL MEDICAL CENTER, A RELATED ORGANIZATION. CAROMONT REGIONAL MEDICAL CENTER UTILIZED THE FOLLOWING METHODS TO DETERMINE APPROPRIATE COMPENSATION FOR OFFICERS THAT HAD INFLUENCE OVER THE ORGANIZATION'S ACTIVITIES: - COMPENSATION COMMITTEE - INDEPENDENT COMPENSATION CONSULTANT - WRITTEN EMPLOYMENT CONTRACTS - COMPENSATION SURVEY OR STUDY - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE PART I, LINES 4A-B THE FOLLOWING INDIVIDUALS RECEIVED DEFERRED COMPENSATION ALLOCATIONS BY RELATED ORGANIZATION CAROMONT REGIONAL MEDICAL CENTER FROM A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP): DAVID O'CONNOR - $ 71,958 MARIA LONG - 59,531 DOUG LUCKETT - 141,984 RANDALL L. KELLEY RECEIVED A SEVERANCE PAYMENT BY RELATED ORGANIZATION CAROMONT REGIONAL MEDICAL CENTER IN THE AMOUNT OF $648,281. PART I, LINE 6 CERTAIN CAROMONT MEDICAL GROUP INC. PHYSICIAN'S COMPENSATION PACKAGES ARE BASED ON THE INDIVIDUAL PHYSICIAN'S NET RESULTS FROM OPERATIONS AS CALCULATED BASED SOLEY ON HIS/HER NET CHARGES LESS HIS/HER ALLOCABLE SHARE OF CLINIC OVERHEAD COSTS. EXECUTIVE INCENTIVE COMPENSATION PLAN FOR ALL KEY EMPLOYEES BASED ON THE ACHIEVEMENT OF ANNUAL BUSINESS OBJECTIVES WHICH INCLUDE A FINANCIAL GOAL ATTRIBUTABLE TO OPERATING MARGIN. MANAGER INCENTIVE PLAN BASED ON CONSOLIDATED CORPORATE AND INDIVIDUAL PERFORMANCE GOALS. FORM 990, PART VI, SECTION A, LINE 1B: BOARD MEMBER INDEPENDENCE: IN CALENDAR YEAR 2014, THE BOARD OF DIRECTORS OF CAROMONT HEALTH CONDUCTED A COMPREHENSIVE REVIEW OF BEST PRACTICES REGARDING INDEPENDENCE OF BOARD MEMBERS. THIS REVIEW RESULTED IN THE DEVELOPMENT OF A BOARD POLICY ON INDEPENDENCE OF BOARD MEMBERS. USING IRS REGULATIONS AND GUIDANCE, INDUSTRY BEST PRACTICES, GUIDANCE AND COMMENTARY APPLICABLE TO NON-PROFIT HEALTHCARE INSTITUTIONS, AND ADVICE OF COUNSEL, THE BOARD OF DIRECTORS DEVELOPED AND IMPLEMENTED A ROBUST POLICY THAT DEFINES INDEPENDENT AND NON-INDEPENDENT DIRECTORS AND CLASSIFIES DIRECTORS ON AN ANNUAL BASIS AS INDEPENDENT AND NON-INDEPENDENT. USING THE IRS REPORTING REQUIREMENTS AS A MINIMUM SET OF CRITERIA FOR DETERMINING THE INDEPENDENT STATUS OF BOARD MEMBERS, THE BOARD'S POLICY GOES BEYOND THE MINIMUM CRITERIA AND DEFINES ADDITIONAL CRITERIA THAT RENDER A BOARD MEMBER NON-INDEPENDENT. ONCE DETERMINED TO HAVE A DISQUALIFYING CONDITION THAT RENDERS THE MEMBER NON-INDEPENDENT, A BOARD MEMBER WHOSE DISQUALIFYING CONDITION HAS BEEN REMEDIED MAY ONLY BE RESTORED TO INDEPENDENT STATUS FOLLOWING A SPECIFIED TIME LIMIT DEFINED IN THE POLICY. IN REPORTING THE NUMBER OF INDEPENDENT DIRECTORS IN PART I, LINE 4 AND PART VI, SECTION A, LINE 1B, CAROMONT MEDICAL GROUP USES THE CAROMONT HEALTH POLICY TO DETERMINE AND REPORT THE INDEPENDENT STATUS OF BOARD MEMBERS. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE CORPORATION SHALL BE CAROMONT HEALTH, INC., A NORTH CAROLINA NOT-FOR-PROFIT CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A THE BOARD OF DIRECTORS SHALL CONSIST OF THREE (3) MEMBERS, ALL OF WHOM SHALL BE APPOINTED BY THE BOARD OF DIRECTORS OF CAROMONT HEALTH, INC. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING POWERS OF THE CORPORATION SHALL BE RESERVED TO CAROMONT HEALTH, INC., THE PARENT CORPORATION AND HOLDING COMPANY OF THE CORPORATION: (A) FINANCIAL POWERS, INCLUDING THE POWER TO APPROVE AN OPERATING BUDGET FOR THE CORPORATION, POWER TO APPROVE COMPENSATION PLANS, AND POWER TO ASSUME DEBT ON BEHALF OF THE CORPORATION; (B) GOVERNING POWERS, INCLUDING THE POWER TO APPROVE ALL CHANGES TO THE GOVERNING DOCUMENTS OF THE CORPORATION AND POWER TO APPROVE THE MISSION, VISION AND VALUES OF THE CORPORATION; AND (C) STRATEGIC POWERS, INCLUDING THE POWER TO APPROVE ALL CERTIFICATE OF NEED APPLICATIONS WHICH THE CORPORATION MAY FILE IN ANY STATE, AND THE POWER TO APPROVE ALL SALE OR LEASE TRANSACTIONS OF THE CORPORATION. FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION'S FORM 990 WAS REVIEWED BY THE AUDIT FINANCE INVESTMENT COMMITTEE OF THE BOARD OF DIRECTORS AND BY THE FULL BOARD BEFORE THE FORM WAS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C EACH EMPLOYEE AND DIRECTOR SHALL FULLY AND TRUTHFULLY COMPLETE A QUESTIONNAIRE CONCERNING POTENTIAL AND ACTUAL CONFLICTS OF INTEREST ANNUALLY. SUCH QUESTIONNAIRE SHALL IDENTIFY THE INDIVIDUAL'S OBLIGATION TO IMMEDIATELY MAKE THE CORPORATE COMPLIANCE OFFICER AWARE IN WRITING OF ANY POTENTIAL OR ACTUAL CONFLICTS OF INTEREST AS THEY MAY ARISE AND CONTAIN SAID INDIVIDUAL'S AGREEMENT TO ABIDE BY ALL TERMS AND CONDITIONS OF THIS POLICY AS A CONDITION OF RETAINING THEIR POSITION. SUCH QUESTIONNAIRES ARE REVIEWED ANNUALLY BY THE CHIEF LEGAL OFFICER AND THE CORPORATE COMPLIANCE OFFICER. QUESTIONNAIRES SUBMITTED BY DIRECTORS ARE REVIEWED ANNUALLY BY THE NOMINATING COMMITTEE OF THE BOARD. FORM 990, PART VI, SECTION B, LINE 15 THE CEO, CFO, COO, CMO AND CHIEF LEGAL OFFICER ARE COMPENSATED FOR THEIR SERVICES BY CAROMONT REGIONAL MEDICAL CENTER, A SUBSIDIARY OF CAROMONT HEALTH, INC. THE COMPENSATION OF ALL CAROMONT EXECUTIVES FOR EACH YEAR IS ESTABLISHED BY THE COMPENSATION COMMITTEE OF THE CAROMONT HEALTH BOARD OF DIRECTORS, BASED ON GUIDANCE AND OPINIONS PROVIDED BY AN INDEPENDENT, THIRD-PARTY COMPENSATION CONSULTANT. BOARD MEMBERS WHO SERVE ON THE COMPENSATION COMMITTEE ARE INDEPENDENT AND FREE OF ANY CONFLICT OF INTEREST. ANY COMPENSATION COMMITTEE MEMBER WHO DEVELOPS A CONFLICT OF INTEREST DURING HIS/HER TERM WITH RESPECT TO THE DISCUSSION OF ANY EXECUTIVE'S COMPENSATION DOES NOT PARTICIPATE IN THE DISCUSSION OR DECISION-MAKING BY THE REMAINING INDEPENDENT MEMBERS OF THE COMPENSATION COMMITTEE. THE COMPENSATION COMMITTEE RETAINS JURISDICTION OVER THE TOTAL COMPENSATION PACKAGE FOR EXECUTIVES AND REVIEWS EXECUTIVE BENEFITS AND PERQUISITES AS WELL AS TOTAL CASH COMPENSATION. COMPENSATION FOR THE CEO IS ESTABLISHED THROUGH A PROCESS OF PERFORMANCE EVALUATION, COMPARISON WITH COMPARABLE MARKET DATA AND DETERMINATION BY THE COMPENSATION COMMITTEE OF ACCEPTABLE SALARY RANGE AND PERCENTILE RANKING. ALL COMPENSATION DECISIONS FOR THE CEO ARE APPROVED BY THE COMPENSATION COMMITTEE, AS LONG AS THE COMPENSATION DECISIONS ARE CONSISTENT WITH THE EXECUTIVE COMPENSATION PHILOSOPHY. THE PROCESS FOR DETERMINING COMPENSATION FOR EXECUTIVE MANAGEMENT, UTILIZES COMPENSATION SURVEYS AND STUDIES. FULL COLLECTED COMPENSATION INFORMATION AND ANY COMPENSATION OPINIONS PROVIDED DURING THESE PROCESSES WILL BE KEPT WITH THE COMPENSATION COMMITTEE OR BOARD MINUTES, AS APPLICABLE. FORM 990, PART VI, SECTION C, LINE 18 THE ORGANIZATION'S FORM 990 IS MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 AT THIS TIME, THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE PUBLIC. THE ENTIRE ORGANIZATION'S COMBINED FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. PART XII, LINE 2C RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT: THIS PROCESS HAS NOT CHANGED FROM PRIOR YEARS. 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