2015-07-14T06:56:30-05:00 2014-08-31 990 2013-09-01 352320780 Bellefonte Physician Services Inc BELL 6068334235 1000 St Christopher Drive Ashland KY 41101 Joe Buchheit Chief Financial Officer-BSKHS 6068364002 2015-07-14 0 2013 2016-02-25 16:41:14Z Kevin Halter 1000 St Christopher Drive Ashland KY 41101 26794588 0 X www.olbh.com/svcs_physicianservices.php X 2008 KY Primary, urgent and specialty care 5 1 288 1 0 0 0 516619 26171523 26114218 -2876 27 37805 163724 26206452 26794588 0 150 0 0 26634111 27580287 0 0 0 11620325 12263683 38254436 39844120 -12047984 -13049532 5561544 6354173 48359281 62201442 -42797737 -55847269 The mission is to bring compassion to health care and to be good help to those in need, especially those who are poor and dying. As a system of caregivers, we commit ourselves to help bring people and communities to health and wholeness. 0 0 36304595 150 26114218 Charity & Indigent Care - Bellefonte Physician Services (BPS) utilizes an affiliate model to provide residents of the tri-state with a variety of services, from primary care to pediatric, urgent and specialty care. A member of the Bon Secours Kentucky Health System, BPS continues to expand to meet the needs of community residents, especially the those in charily and indigent need. The various practices that comprise BPS are strategically located throughout the region to bring the highest quality health care close to home with convenient locations. 36304595 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 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 0 1 0 0 0 1 60 0 1 288 1 0 0 0 0 0 0 0 0 0 0 X 5 1 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X Joe Buccheit 6068333700 1000 St Christopher Dr Ashland KY 41101 X Kevin Halter FACHE Chairman/CEO-BSKY 10.00 40.00 X X 0 397047 50246 Augustinus Lobach MD Board Member 0.50 49.50 X 0 251868 14207 Thomas Morris PhD President (Jan-Aug) 0.50 49.50 X X 0 404206 56063 James Payne PhD Board Member 0.50 0.00 X 0 0 0 Samuel Ross MD Board Member 0.50 49.50 X 0 691072 84352 John Wallenhorst PhD President (Sep-Dec) 0.50 49.50 X X 0 337082 24753 Joe Buchheit Treasurer/CFO-BSKY 10.00 40.00 X 0 294689 22721 Tyler Walters Secretary 0.50 49.50 X 0 82622 24466 Charles Rhodes MD Cardiologist 50.00 0.00 X 859111 0 29368 Mohamad Abul-Khoudoud MD Pulmonologist 50.00 0.00 X 613938 0 20865 Richard Mailloux MD Gastroenterologist 50.00 0.00 X 557885 0 36870 Brian Defade MD Urologist 50.00 0.00 X 529678 0 20982 Harry Bell MD Physiatrist 50.00 0.00 X 419467 0 26047 James Fuzy Former Secretary 0.00 0.00 X 0 185632 12100 2980079 2644218 423040 42 1 1 0 AthenaHealth Inc 311 Arsenal Court Watertown MA 02472 Billing Agent 1037488 Roland Benton PSC 413 Country Club Drive Ashland KY 41101 Contract Physician 352706 Regional Psychotherapy Services 1000 Ashland Drive Suite 301 Ashland KY 41101 Contract Physician Fees 137754 Dirtbusters Janitorial Services 6433 Route 60 Suite 100 Barboursville WV 25504 Cleaning Services 108035 4 516619 516619 Patient Service Rev. 621110 26114218 26114218 26114218 27 27 EKG Reading Fees 900099 108659 108659 Gift Shop 900099 21537 21537 Skin Care 900099 16585 16585 16943 16943 163724 26794588 26114218 0 163751 150 150 22608662 20347796 2260866 761893 685704 76189 2555748 2300173 255575 1653984 1488586 165398 8931 8038 893 674877 674877 31100 27990 3110 426450 383805 42645 6568 5911 657 3071189 2764070 307119 126279 113651 12628 29217 26295 2922 74121 74121 668777 601899 66878 604969 544472 60497 Purchased Services 2260974 2034877 226097 Bad Debt 1939182 1939182 Medical Supplies 1760528 1760528 Physician Recruitment 276368 248731 27637 304153 273739 30414 39844120 36304595 3539525 0 3707 5260 330666 252213 1582004 2069748 15317 1632 266238 248996 1776964 2006881 3700544 2379767 948227 1320777 638421 448666 5561544 6354173 1341222 1157780 36060 47018059 61007602 48359281 62201442 X -42797737 -55847269 -42797737 -55847269 5561544 6354173 -13049532 0 X 0 1 X 1 1 1 X 212500 516619 729119 14491266 20632747 23624340 26171523 26114218 111034094 14491266 20845247 23624340 26171523 26630837 111763213 0 0 0 111763213 105 39 44 30 27 245 105 39 44 30 27 245 16140 17849 21944 37805 163724 257462 14507511 20863135 23646328 26209358 26794588 112020920 0.99770 0.99890 0.00000 X Schedule A, Part III, Line 12, Explanation of Other Income: Skin Care - 2009 Amount: $ 15,410. 2010 Amount: $ 17,154. 2011 Amount: $ 18,116. 2012 Amount: $ 31,606. 2013 Amount: $ 16,585. Purchase Discounts - 2009 Amount: $ 730. 2010 Amount: $ 695. 2011 Amount: $ 3,828. 2012 Amount: $ 6,199. EKG Reading Fees - 2013 Amount: $ 108,659. Gift Shop - 2013 Amount: $ 21,537. All Other Revenue - 2013 Amount: $ 16,943. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 98505 20160 78345 269363 40298 229065 3198650 2302791 895859 134026 16518 117508 1320777 Misc Receivables 448666 448666 Due to BSHSI 61007267 Due to Affiliate 335 61007602 X Part X, Line 2: Schedule D, Part X, Line 2 requires that the organization provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under ASC 740. ASC 740 addresses the accounting for uncertainty in income taxes recognized in an entity's financial statements and prescribes a threshold of more-likely-than-not for recognition and derecognition of tax positions taken or expected to be taken in a tax return. The adoption of ASC 740 by BSHSI on September 1, 2007 did not have a material impact on BSHSI's consolidated financial statements. As the organization does not conduct a separate audit of its financial statements, below is the related statement from the Bon Secours Health System, Inc. consolidated audited financial statements: The System and most of its subsidiaries (including certain joint venture entities) are exempt from federal income taxes under Section 501(c)(3) of the Internal Revenue Code of 1986, as amended. The system accounts for uncertain tax positions in accordance with ASC Topic 740. Income taxes of the System's for-profit subsidiaries are not material to the accompanying consolidated financial statements. The System's taxable subsidiaries have approximately $61,513 and $66,681 of net operating loss carryforwards as of August 31, 2014 and 2013, respectively, which expire in varying periods through 2034 and are available to offset future taxable income. The System's deferred tax assets are fully reserved at August 31, 2014 and 2013. Any changes to the valuation allowance on the deferred tax asset are reflected in the year of the change. X 0 0 0 1 0 0 0 0 0 0 0 Kevin Halter FACHE Chairman/CEO-BSKY 0 302354 0 49988 0 44705 0 23626 0 26620 0 447293 0 1525 Augustinus Lobach MD Board Member 0 201903 0 22885 0 27080 0 4104 0 10103 0 266075 0 2813 Thomas Morris PhD President (Jan-Aug) 0 286607 0 77693 0 39906 0 36404 0 19659 0 460269 0 11391 Samuel Ross MD Board Member 0 544818 0 78880 0 67374 0 64863 0 19489 0 775424 0 9962 John Wallenhorst PhD President (Sep-Dec) 0 225989 0 63875 0 47218 0 14568 0 10185 0 361835 0 801 Joe Buchheit Treasurer/CFO-BSKY 0 220097 0 29649 0 44943 0 4536 0 18185 0 317410 0 3075 Charles Rhodes MD Cardiologist 818437 0 19300 0 21374 0 11475 0 17893 0 888479 0 0 0 Mohamad Abul-Khoudoud MD Pulmonologist 325472 0 282746 0 5720 0 3825 0 17040 0 634803 0 0 0 Richard Mailloux MD Gastroenterologist 542394 0 0 0 15491 0 11475 0 25395 0 594755 0 0 0 Brian Defade MD Urologist 416239 0 95475 0 17964 0 11475 0 9507 0 550660 0 0 0 Harry Bell MD Physiatrist 389873 0 20908 0 8686 0 7650 0 18397 0 445514 0 0 0 James Fuzy Former Secretary 0 167215 0 17350 0 1067 0 6384 0 5716 0 197732 0 0 Part I, Line 1a Tax indemnification and gross-up: Certain full time individuals (4) listed on Form 990, Part VII received gift cards valued at $100. The value of the gift cards were reported as taxable compensation. In an effort to reduce the tax impact of these gifts, each recipient received additional taxable compensation of $50 which was added to their paycheck. Part I, Line 3 Bon Secours Health System, Inc., a related organization of the filing organization, uses the following to establish the compensation of the organization's CEO/Executive Director: Compensation Committee Independent Compensation Consultant Written Employment Contract Compensation Survey or Study Approval by the Board or Compensation Committee Part I, Line 4b The filing organization participates in a BSHSI sponsored executive retirement program that allows for deposits into additional retirement plans and is available only to officers and key employees. The 457F plan is a non-qualified plan and is subject to a minimum three-year service requirement before vesting on deposits made into this plan. Individuals that received a distribution include: Joe Buchheit, $3,956; Kevin Halter, FACHE, $3,706; Augustinus Lobach, MD, $5,460; Samuel Ross, MD, $21,465; John Wallenhorst, PhD, $903; Thomas Morris, PhD, $17,448. Form 990, Part VI, Section A, line 6 Bon Secours Health System, Inc is the sole member of Bon Secours Kentucky Health System, which in turn is the sole member of Bellefonte Physician Services, Inc. Form 990, Part VI, Section A, line 7a The governing body of Bellefonte Physician Services, Inc. is appointed by its Member, Bon Secours Kentucky Health System, Inc. and subject to approval by Bon Secours Health System, Inc. Form 990, Part VI, Section A, line 7b Certain authorities of Bellefonte Physician Services, Inc. are reserved to its member or to Bon Secours Health System, Inc. Form 990, Part VI, Section B, line 11 The process the organization uses to review the Form 990 consists of a review by the local system's audit and compliance board-committee and providing the form to the local system board of directors to allow for a thorough review by both before the filing date. The local system's audit and compliance committee and board of directors have reviewed the Form 990, scheduled time on meeting agendas, and asked questions regarding the Form 990 before the return is filed. Form 990, Part VI, Section B, line 12c The organization regularly and consistently monitors compliance with the conflict of interest policy. On an annual basis, all persons subject to the policy, including all officers, directors and key employees are required to make certain disclosures. These include disclosures related to certain personal, financial and organizational relationships that may present a conflict, or the appearance of a conflict of interest with the organization. All disclosures go through a three-part review process: (1) disclosures are reviewed first by the corporate responsibility officer (CRO); (2) a governance team comprised of the CEO, board president, board chair, CRO, and the BSHSI CRO participate in a second review of all disclosures during which recommendations are made as to the resolution of any conflicts or potential conflicts. Depending on the facts and circumstances, resolutions may include ongoing disclosure, recusal or removal of the conflict; and (3) all disclosures and recommendations are reviewed by a board committee (audit and compliance committee reviews the disclosures of management and the governance committee reviews the disclosures of the board and board committee members). Form 990, Part VI, Section B, line 15 The compensation committee of the board of Bon Secours Health System, Inc. (BSHSI) engages in a comprehensive process for the oversight and management of remuneration for executive employees and disqualified parties of the BSHSI. The compensation committee consists of a group of independent board members and engages an independent external compensation consultant to ensure they receive appropriate analysis of market and follow the practices necessary to obtain full compliance with the IRS' rebuttable presumption of reasonableness. The committee establishes and maintains a compensation philosophy; reviews pay practices against local, regional and national healthcare organizations and approves all remunerative decisions for this group of individuals. The committee reviews and receives assurances that all levels of pay within the organization are reasonable based on performance and validates incentives are met. These decisions are documented in the BSHSI board of directors' and compensation committee minutes. Form 990, Part VI, Section b, Line 15b - Compensation Process Other Officers/ Key Employees: For those key employees and highest paid employees that are not reviewed by the BSHSI compensation committee, the process included a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision. In the review, the other officers or key employees of the organization were compared to other hospitals' employees in the area that hold the same title. During the review and approval of the compensation, documentation of the decision was recorded in human resources. Form 990, Part VI, Section C, line 19 The filing organization provides any documents open to public inspection upon request. Form 990, Part VII Board Member positions are generally voluntary in nature. Compensated employees of the filing organization and other related organizations who also hold board positions are compensated only in relation to their employment and do not receive additional compensation for their board responsibilities. Bon Secours Health System Inc 1505 Marriottsville Road Marriottsville MD 21104 521301088 Parent Org. - Management Services MD 501(c)(3) Line 11c, III-FI Bon Secours Inc 0 Our Lady of Bellefonte Hospital Inc 1000 St Christopher Drive Ashland KY 41101 611356023 Healthcare KY 501(c)(3) Line 3 Bon Secours Kentucky Health System 0 Our Lady of Bellefonte Hospital Foundation 1000 St Christopher Drive Ashland KY 41101 611381952 Grant Making Foundation KY 501(c)(3) Line 9 Bon Secours Kentucky Health System 0 Bon Secours Kentucky Health System 1000 St Christopher Drive Ashland KY 41101 611356024 Local System Parent Org. KY 501(c)(3) Line 11c, III-FI Bon Secours Health System Inc 0 0 0 0 0 1 0 0 0 0 0 1 0 1 0 0 1 0 0 0