2015-11-13T14:43:54-06:00 2014-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2014-01-01 420860039 STEWART MEMORIAL COMMUNITY HOSPITAL STEW 7124644200 1301 W MAIN LAKE CITY IA 51449 JIM HENKENIUS CHIEF FINANCIAL OFFICER 7124644200 2015-11-12 1 BARBARA J FAJEN P00400874 4023302660 2014 2016-04-25 22:37:26Z JIM HENKENIUS 1301 W MAIN LAKE CITY IA 51449 32876475 0 X WWW.STEWARTMEMORIAL.ORG X 1958 IA TO PROVIDE A COMPLETE CONTINUUM OF HEALTHCARE SERVICES TO THE PEOPLE OF LAKE CITY AND THE SURROUNDING COMMUNITIES WITHOUT REGARD FOR ABILITY TO PAY AND WITHOUT DISCRIMINATION. 9 8 313 125 4845662 -815535 127567 53713 29599247 30466632 292906 459202 241360 266790 30261080 31246337 0 0 0 0 15195756 15352287 0 0 0 15968973 16534276 31164729 31886563 -903649 -640226 19006154 18021265 8413580 8332082 10592574 9689183 STEWART MEMORIAL COMMUNITY HOSPITAL IS COMMITTED TO PROVIDING QUALITY HEALTHCARE WITH A PERSONAL TOUCH AND RESPONDING TO THE NEEDS OF THE COMMUNITIES AND PEOPLE WE SERVE. 0 0 28787284 25620970 STEWART MEMORIAL COMMUNITY HOSPITAL (SMCH) IS A COMPLETE RURAL HEALTH DELIVERY SYSTEM LOCATED IN LAKE CITY, IOWA. SERVICES PROVIDED INCLUDE INPATIENT, OUTPATIENT, PHYSICIAN CLINIC, HOMECARE, RETAIL PHARMACY, COMMUNITY WELLNESS, AND MANY OTHER RELATED HEALTHCARE PROGRAMS. SMCH IS ALSO AN APPROVED CRITICAL ACCESS HOSPITAL THAT PROVIDES EMERGENCY, OUTPATIENT AND SHORT-TERM INPATIENT SERVICES. 28787284 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 38 0 1 313 1 1 1 0 0 0 0 1 1 0 0 0 0 X 9 8 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X JIM HENKENIUS CFO 7124644200 1301 W MAIN STREET LAKE CITY IA 51449 CHARLES SCHMITT BOARD CHAIR 2.00 0.00 X X 0 0 0 MARY WARNER VICE CHAIR 2.00 0.00 X X 0 0 0 HEATHER MCCLUE SECRETARY 2.00 0.00 X X 0 0 0 BRADLEY LANE TREASURER 2.00 0.00 X X 0 0 0 DEBRA LIGHTNER DIRECTOR 1.00 0.00 X 0 0 0 SCOTT NESBITT DIRECTOR 1.00 0.00 X 0 0 0 LINDA BETTIN DIRECTOR 1.00 0.00 X 0 0 0 CHADRIC DIETRICH DIRECTOR 1.00 0.00 X 0 0 0 DR DAVID FRATE MEDICAL COUNSEL 40.00 0.00 X 484283 0 4430 HEATHER CAIN CEO 40.00 0.00 X 0 0 0 JIM HENKENIUS CFO 40.00 0.00 X 129193 0 23124 DEREK DUNCAN D.O. 40.00 0.00 X 518541 0 18726 ADAM SWISHER D.O. 40.00 0.00 X 415105 0 23788 SUSAN HORNBACK D.O. 40.00 0.00 X 494293 0 28820 MARK MOGENSEN PA-C 40.00 0.00 X 217757 0 23078 PERRY HENELY CRNA 40.00 0.00 X 207473 0 20084 2466645 0 142050 19 0 1 1 LEE D HIEB MD 524 W 4TH STREET LOGAN IA 51546 ORTHOPAEDIC SERVICES 306317 WESTERN IOWA SURGERY 311 S CLARK STREET SUITE 280 CARROLL IA 51401 GENERAL SURGERY SERVICES 183350 HEALTHNET CONNECT 1776 WEST LAKES PARKWAY SUITE 400 W DES MOINES IA 50266 IT CONTRACTED SERVICES 160926 LOCUM TENENSCOM LLC PO BOX 405547 ATLANTA GA 30384 ER PHYSICIAN LOCUM TENENS 151861 LAURIE CONNOLLY MD 1217 W LINCOLN WAY JEFFERSON IA 50129 ER PHYSICIAN SERVICES 109450 7 4378 49335 53713 MEDICARE/MEDICAID REVENUE 621400 13232169 13232169 PATIENT SERVICE REVENUE 621400 9892922 9892922 RETAIL PHARMACY REVENUE 446110 4845662 4845662 340B PROGRAM REVENUE 621400 2001909 2001909 EHR INCENTIVE PAYMENT 621400 276923 276923 217047 217047 30466632 79100 79100 97052 48706 48346 48346 48346 1945995 11096 1576989 0 369006 11096 380102 380102 22449 4378 4443 18006 18006 CAFETERIA SALES 900099 200438 200438 200438 31246337 25620970 4845662 725992 X 641030 488713 152317 11557524 10478739 1078785 248179 226670 21509 2143608 1948120 195488 761946 691724 70222 360482 360482 43948 43948 84592 84592 25520 25520 3199097 2998641 200456 157554 98838 58716 938258 810346 127912 296579 296579 366746 366746 258979 138840 120139 184026 184026 1251438 1123833 127605 140762 140762 RETAIL PHARMACY EXPENSE 4942608 4942608 MEDICAL SUPPLIES 3161121 3161121 BAD DEBT 648862 648862 FOOD 198529 198529 275175 140166 135009 31886563 28787284 3099279 0 409772 72585 950211 1153669 4321756 3947596 43093 43093 1488549 1496427 86439 80038 28963274 20478805 8421398 8484469 3029841 2069922 255095 673466 19006154 18021265 3591373 3637274 3090000 2765000 1350772 1929808 381435 0 8413580 8332082 X 10592574 9689183 10592574 9689183 19006154 18021265 -640226 -263165 0 X X 0 1 X 1 0 X 171513 171513 5937442 4466700 1470742 20841281 15033437 5807844 2013038 978668 1034370 8484469 X 30387459 -263165 53149 -210016 30597475 648862 648862 31246337 31290850 53149 53149 31237701 648862 648862 31886563 PART X, LINE 2: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE CODE AND HAS RECEIVED A DETERMINATION LETTER THAT IT IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN THE HOSPITAL'S TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HOSPITAL TO MEET A COMMUNITY BENEFITS STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2014 AND 2013, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. WITH FEW EXCEPTIONS, THE HOSPITAL IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS ENDED PRIOR TO DECEMBER 31, 2011. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 48,706. FUNDRASING EXPENSES 4,443. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 648,862. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 48,706. FUNDRAISING EXPENSE 4,443. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 648,862. TABLE A FARE 5907 748 5159 24 724 TRIVIA NIGHT 20920 3630 17290 170 47 65 1900 300 1213 26827 4378 22449 170 71 65 2624 300 1213 4443 18006 1 1 1 X 1 X 100.000000000000 0 1 0 1 1 166 108490 0 108490 0.00350 3206299 2617268 589031 0.01890 166 3314789 2617268 697521 0.02240 13 8868 156228 38216 118012 0.00380 3 12 42793 42793 0.00140 5 40 15510 15510 0.00050 21 8920 214531 38216 176315 0.00570 21 9086 3529320 2655484 873836 0.02810 1 600 600 0.00000 1 1575 1575 0.00010 2 2175 2175 0.00010 1 648862 0 9535802 9806326 -270524 X 1 0 1 1 STEWART MEMORIAL COMMUNITY HOSPITAL 1301 WEST MAIN STREET LAKE CITY IA 51449 WWW.STEWARTMEMORIAL.ORG 130029H X X X X STEWART MEMORIAL COMMUNITY HOSPITAL 1 0 0 1 X X X X X X 12 1 0 0 1 X WWW.STEWARTMEMORIAL.ORG X 0 0 1 X 200.000000000000 100.000000000000 X 1 1 1 X X 1 X 0 X 1 X 0 0 STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 5: STEWART MEMORIAL COMMUNITY HOSPITAL (SMCH) CREATED A COMMUNITY NEEDS ASSESSMENT AND MADE IT AVAILABLE TO STAFF, COMMUNITY MEMBERS, MEMBERS OF THE COUNTY PUBLIC HEALTH DEPARTMENT, LOCAL SCHOOLS AND OTHER ORGANIZATIONS. THE SURVEY WAS CREATED ONLINE AND ALLOWED FOR TABULATION OF RESPONSES AND IDENTIFIED NEEDS. THE SURVEY WAS PROMOTED VIA SMCH'S WEBSITE, EMAIL CAMPAIGN AND PAPER FLIERS. SMCH ALSO PARTNERED WITH AND USED INPUT FROM THE COUNTY PUBLIC HEALTH DEPARTMENT AS THEY HAD PREVIOUSLY CONDUCTED A COMMUNITY HEALTH NEEDS SURVEY IN 2012. SMCH WILL CONDUCT ANOTHER ASSESSMENT IN 2015. STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 11: SMCH CREATED A COMMUNITY NEEDS/WELLNESS COMMITEE AT THE HOSPITAL TO LOOK AT AND ADDRESS THE ISSUES IDENTIFIED IN THE COMMUNITY NEEDS SURVEY. SMCH STARTED WITH THEIR EMPLOYEES, GETTING BASELINE DATA FOR IMPROVING THEIR HEALTH AND WELLNESS. SMCH IS DEVELOPING A PLAN WITHIN THEIR ORGANIZATION TO ADDRESS THE GREATEST CONCERNS AND THOSE THAT THEY CAN IMPACT DIRECTLY. SMCH IS CONDUCTING ANOTHER ASSESSMENT IN 2015 AND WILL USE THOSE RESULTS TO CREATE AND ADOPT AN IMPLEMENTATION PLAN TO IMPROVE THEIR ORGANIZATION AND COMMUNITY NEEDS. STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 13H: SMCH HAS A SPREADSHEET BASED ON THE FEDERAL POVERTY GUIDELINES TO DETERMINE DISCOUNTED CARE. THE SPREADSHEET ALSO ACCOUNTS FOR THE FAMILY SIZE IN DETERMINING ELIGIBILITY. FOR THOSE APPLYING, IF THEIR INCOME FALLS BETWEEN 225-250% OF THE GUIDELINES, 75% OF THE PATIENT'S BILL IS FORGIVEN; IF THE INCOME IS BETWEEN 300-400% OF THE GUIDELINES, 50% IS FORGIVEN. STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 22D: IT IS THE POLICY OF THE HOSPITAL TO DETERMINE ELIGIBILITY FOR THE FINANCIAL ASSISTANCE PROGRAM AFTER CARE IS ADMINISTERED. 4 MCCRARY-ROST CLINIC 1351 WEST MAIN STREET LAKE CITY IA 51449 HEALTH CLINIC GOWRIE CLINIC 1800 MAIN GOWRIE IA 50543 HEALTH CLINIC LAKE VIEW CLINIC 1160 3RD STREET LAKE VIEW IA 51540 HEALTH CLINIC ROCKWELL CITY CLINIC 505 EAST LAKE STREET ROCKWELL CITY IA 50579 HEALTH CLINIC PART I, LINE 3C: NOT APPLICABLE PART I, LINE 6A: STEWART MEMORIAL COMMUNTIY HOSPITAL'S COMMUNITY BENEFIT REPORT IS NOT PREPARED BY A RELATED ORGANIZATION. PART I, LINE 7: STEWART MEMORIAL COMMUNITY HOSPITAL USED THE WORKSHEETS PROVIDED IN THE IRS INSTRUCTIONS FOR SCHEDULE H IN ADDITION TO THE INTERNAL COST ACCOUNTING SYSTEM. PART I, LINE 7G: THERE ARE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. PART I, LN 7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $648,862. PART II, COMMUNITY BUILDING ACTIVITIES: TWO MEMBERS OF THE ORGANIZATION ARE VOLUNTEER MEMBERS ON THE LOCAL BETTERMENT ORGANIZATION. AT THE MONTHLY MEETINGS, THEY USE THEIR TIME TO PROMOTE THE SERVICES AND WELLNESS ACTIVITIES THE HOSPITAL PROVIDES. CURRENT AND PROSPECTIVE BUSINESSES UNDERSTAND THE VARIOUS HEALTH SERVICES THAT ARE MADE AVAILABLE TO THEM AND THEIR EMPLOYEES. THE VP AND AN EMPLOYED PHYSICIAN ARE MEMBERS OF THE CALHOUN COUNTY BOARD OF HEALTH. PART III, LINE 2: IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND ESTIMATES A PERCENTAGE OF THOSE ACCOUNTS THAT WILL TRANSITION TO SELF-PAY PATIENTS BASED ON HISTORICAL ANALYSIS. THE ESTIMATED PERCENTAGE OF THOSE TRANSITION ACCOUNTS ARE ADDED TO RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL). THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS.PAYMENT FOR SERVICES IS EXPECTED WITHIN THIRTY DAYS OF RECEIPT OF THE BILLING. ACCOUNTS CONSIDERED PAST DUE ARE SENT TO COLLECTION AGENCIES WHEN EXTERNAL COLLECTION EFFORTS HAVE BEEN UNSUCCESSFUL. ANY AMOUNTS DEEMED UNCOLLECTIBLE ARE WRITTEN OFF ON A MONTHLY BASIS. THE HOSPITAL DOES NOT CHARGE INTEREST ON OUTSTANDING BALANCES OWED. PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, THE FOLLOWING IS THE TEXT OF THE FOOTNOTES TITLED "PATIENT RECEIVABLES, NET," "NET PATIENT SERVICE REVENUE," AND "CHARITY CARE." PATIENT RECEIVABLES, NET:THE HOSPITAL REPORTS PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYERS, PATIENTS AND OTHERS. ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND ESTIMATES A PERCENTAGE OF THOSE ACCOUNTS THAT WILL TRANSITION TO SELF-PAY PATIENTS BASED ON HISTORICAL ANALYSIS. THE ESTIMATED PERCENTAGE OF THOSE TRANSITION ACCOUNTS ARE ADDED TO RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL). THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS.PAYMENT FOR SERVICES IS EXPECTED WITHIN THIRTY DAYS OF RECEIPT OF THE BILLING. ACCOUNTS CONSIDERED PAST DUE ARE SENT TO COLLECTION AGENCIES WHEN EXTERNAL COLLECTION EFFORTS HAVE BEEN UNSUCCESSFUL. ANY AMOUNTS DEEMED UNCOLLECTIBLE ARE WRITTEN OFF ON A MONTHLY BASIS. THE HOSPITAL DOES NOT CHARGE INTEREST ON OUTSTANDING BALANCES OWED.NET PATIENT SERVICE REVENUE:THE HOSPITAL HAS AGREEMENTS WITH THIRD-PARTY PAYORS THAT PROVIDE FOR PAYMENTS TO THE HOSPITAL AT AMOUNTS DIFFERENT FROM ITS ESTABLISHED RATES. PAYMENT ARRANGEMENTS INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE, REIMBURSED COSTS, DISCOUNTED CHARGES AND PER DIEM PAYMENTS. NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, RESIDENTS, THIRD-PARTY PAYORS, AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYORS. RETROACTIVE ADJUSTMENTS ARE ACCRUED ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED AND ADJUSTED IN FUTURE PERIODS AS FINAL SETTLEMENTS ARE DETERMINED.CHARITY CARE:TO FULFILL ITS MISSION OF COMMUNITY SERVICE, THE HOSPITAL PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS PATIENT SERVICE REVENUE.THE HOSPITAL IS DEDICATED TO PROVIDING COMPREHENSIVE HEALTHCARE SERVICES TO ALL SEGMENTS OF SOCIETY, INCLUDING THE AGED AND OTHERWISE ECONOMICALLY DISADVANTAGED. IN ADDITION, THE HOSPITAL PROVIDES A VARIETY OF COMMUNITY HEALTH SERVICES AT OR BELOW COST.THE BAD DEBT EXPENSE DOES NOT INCLUDE ANY PATIENTS ELIGIBLE UNDER OUR CHARITY CARE POLICY SINCE THEY ARE LISTED SEPARATELY IN THE GENERAL LEDGER. BAD DEBT EXPENSE IS NOT LISTED IN OUR COMMUNITY BENEFITS. PART III, LINE 8: NO MEDICARE SHORTFALL IS TREATED AS COMMUNITY BENEFIT. THE 2014 FILED MEDICARE COST REPORT WAS USED TO DETERMINE THE ALLOWABLE COSTS. PART III, LINE 9B: COLLECTION POLICY:PATIENTS ARE ADMITTED INTO THE HOSPITAL COMPUTER SYSTEM WITH APPROPRIATE FINANCIAL INFORMATION INCLUDING INSURANCE INFORMATION AND ARE ASSIGNED A FINANCIAL CLASS (F/C) USED TO SEGREGATE ACCOUNTS IN ACCOUNTS RECEIVABLE (A/R) BY PAYER TYPE. PATIENTS WHO ARE MINORS ARE ADMITTED WITH THE PARENT WHO CARRIES THE INSURANCE COVERAGE AS THE RESPONSIBLE PARTY OR IF NO INSURANCE, THE PARENT WHO BROUGHT THE CHILD IN FOR CARE IS LISTED AS GUARANTOR.THE BUSINESS OFFICE WILL SEND AN ITEMIZED STATEMENT OF CHARGES TO ALL PATIENTS WHO REQUEST A COPY. INSURANCE COMPANIES ARE BILLED ELECTRONICALLY THROUGH THE USE OF EMDEON SOFTWARE WHENEVER POSSIBLE. ONCE THE INSURANCE COMPANY HAS PROCESSED THE CLAIM AND PAID ITS ENTIRE SHARE OR IF THE PATIENT DOESN'T HAVE INSURANCE, THEY WILL BE ASSIGNED A FINANCIAL CLASS OF SELF-PAY. SMCH ALLOWS PATIENTS TO SET UP PAYMENT ARRANGEMENTS FOLLOWING THIS SCHEDULE USING CHECK, MONEY ORDER, MASTERCARD OR VISA:BALANCE IS: MINIMUM PAYMENT:UNDER $250 $ 25.00 $251-$500 $ 50.00$501-$1000 $ 100.00$1001 - ABOVE $ 150.00THESE LIMITS ARE SET TO INSURE BALANCES ARE PAID IN FULL WITH 18 MONTHS IF AT ALL POSSIBLE. WHEN THE PATIENT IS ASSIGNED A FINANCIAL CLASS OF P, THE ACCOUNT IS SENT TO MED-PLAN FOR EARLY OUT PRE-COLLECT PROCESSING. THE FIRST STATEMENT FROM MED-PLAN IS MAILED OUT ON DAY 1 WHEN THEY RECEIVE THE ACCOUNT AND THEN AGAIN AT 30 DAYS. ACCOUNTS THAT DO NOT MAKE PAYMENT ARRANGEMENTS OR MAKE PAYMENTS FROM THE LETTER CAMPAIGN AFTER 45 DAYS ARE MOVED INTO A TELEPHONE CAMPAIGN. THE TELEPHONE CAMPAIGN MAKES 3 ATTEMPTS OVER 15 DAYS TO SECURE PAYMENT IN FULL OR A SCHEDULED PAYMENT PLAN. IF RESOLUTION ATTEMPTS FAIL AND MED-PLAN IS UNABLE TO RESOLVE AN ACCOUNT BECAUSE (1) IT IS IMPOSSIBLE TO REACH A PATIENT BY TELEPHONE, OR (2) THE PATIENT HAS FAILED TO COOPERATE IN ESTABLISHING A PAYMENT PLAN, OR (3) THE PATIENT HAS FAILED TO HONOR AN ESTABLISHED PLAN BY NOT MAKING SATISFACTORY PAYMENT WITHIN 60-90 DAYS, A FINAL NOTICE WILL BE SENT TO THE PATIENT. ACCOUNTS UNPAID OR ARRANGEMENTS NOT MADE AT THIS POINT IN THE BILLING PROCESS ARE DETERMINED UNCOLLECTIBLE. IF NO PAYMENT IN ALLOWABLE TIME IS RECEIVED, ACCOUNTS ARE ELECTRONICALLY SENT TO A COLLECTION AGENCY. IN THE EVENT OF PARTIAL PAYMENT, A DETERMINATION ON AN INDIVIDUAL BASIS IS MADE AS TO STOP OR PROCEED WITH THE COLLECTION AGENCY. PART VI, LINE 2: SMCH COLLABORATES WITH THE COUNTY HEALTH DEPARTMENT IN ASSESSING THE HEALTH CARE NEEDS OF THE COMMUNITIES THEY SERVE. SMCH ALSO EVALUATES USAGE DATA THROUGH THE IOWA HOSPITAL ASSOCIATION TO SEE THE PRIMARY MEDICAL DIAGNOSIS IN THEIR COMMUNITIES. PART VI, LINE 3: SMCH HAS A PATIENT ACCOUNTS MANAGER AS WELL AS A SOCIAL WORKER ON STAFF THAT IDENTIFY PATIENTS THAT MAY BE ELIGIBLE FOR ASSISTANCE OR QUALIFY FOR CHARITY CARE. THEY ASSIST THE PATIENT WITH AVAILABLE OPTIONS AND/OR THE NECESSARY PAPERWORK. PART VI, LINE 4: THE SERVICE AREA IS A 35 MILE RADIUS SURROUNDING THEIR COMMUNITY. THIS AREA CONSISTS OF MANY SMALL, RURAL COMMUNITIES THAT ARE AGRICULTURAL BASED. THE PATIENT BASE CONSISTS OF A LARGE MEDICARE POPULATION. PART VI, LINE 5: SMCH PROVIDES THE COMMUNITIES WITH LABORATORY WELLNESS TESTING AND EDUCATIONAL PROGRAMS ON PROMOTING HEALTHY LIFESTYLES. THEY PROVIDE CARE TO THE INDIGENT REGARDLESS OF THEIR ABILITY TO PAY. THE BOARD OF DIRECTORS ARE REPRESENTED BY THE VARIOUS COMMUNITIES THEY SERVE. PART VI, LINE 6: THE HOSPITAL HAS JOINED WITH THE COUNTY DEPARTMENT OF HEALTH IN ESTABLISHING A PROGRAM CALLED "CARING HANDS CLOSET." CARING HANDS CLOSET IS A PROGRAM FOR EXPECTING MOTHERS AND NEW MOTHERS TO EARN POINTS TOWARDS BABY ITEMS BY ATTENDING THEIR DOCTOR APPOINTMENTS AND/OR EDUCATIONAL PROGRAMS. SMCH PROVIDES MONTHLY LABORATORY WELLNESS TESTING AND EDUCATIONAL PROGRAMS BI-MONTHLY. PART VI, LINE 7, REPORTS FILED WITH STATES IA X X X 0 0 0 0 0 0 0 0 0 DR DAVID FRATE MEDICAL COUNSEL 407527 0 76586 0 170 0 4430 0 0 0 488713 0 0 0 JIM HENKENIUS CFO 129041 0 0 0 152 0 3955 0 19169 0 152317 0 0 0 DEREK DUNCAN D.O. 369456 0 148905 0 180 0 2958 0 15768 0 537267 0 0 0 ADAM SWISHER D.O. 381367 0 33594 0 144 0 5711 0 18077 0 438893 0 0 0 SUSAN HORNBACK D.O. 404023 0 90000 0 270 0 6065 0 22755 0 523113 0 0 0 MARK MOGENSEN PA-C 207656 0 10000 0 101 0 3379 0 19699 0 240835 0 0 0 PERRY HENELY CRNA 206822 0 0 0 651 0 5939 0 14145 0 227557 0 0 0 FORM 990, PART VII, LINE 5: HEATHER CAIN, CEO, RECEIVED COMPENSATION FROM TRINITY HEALTH SYSTEMS, AN UNRELATED ENTITY, WHICH PROVIDES MANAGEMENT SERVICES TO ITS CLIENTS. MS. CAIN RECEIVED A BASE COMPENSATION OF $147,691 FOR HER SERVICES DURING THE CALENDAR YEAR 2014. HER COMPENSATION IS REPORTED IN PART IX, LINE 11A. A CITY OF LAKE CITY IOWA 426004850 508021AQ5 2006-02-08 5000000 CAPITAL IMPROVEMENTS 0 0 0 A 2235000 5148809 489970 4658839 2008 0 0 1 1 A 0 0 0 0 0 0 0 A 0 0 1 1 0 0 0 0 0 A 0 PART II, LINE 3: THE TOTAL PROCEEDS DO NOT AGREE TO THE ISSUE PRICE IN PART I, COLUMN (E) DUE TO INVESTMENT EARNINGS. PART IV, ARBITRAGE, LINE 2C: (A) ISSUER NAME: CITY OF LAKE CITY, IA DATE THE REBATE COMPUTATION WAS PERFORMED: 01/31/2011 PART V STEWART MEMORIAL COMMUNITY HOSPITAL IS IN THE PROCESS OF ADOPTING VCAP PROCEDURES. FORM 990, PART VI, SECTION A, LINE 3 TRINITY HEALTH SYSTEMS AND STEWART MEMORIAL COMMUNITY HOSPITAL HAVE AN AGREEMENT FOR ADMINISTRATIVE SERVICES. TRINITY HEALTH SYSTEMS PROVIDED THE SERVICES OF HEATHER CAIN, CEO SINCE 01/01/14. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 WILL BE PROVIDED ELECTRONICALLY TO THE BOARD OF DIRECTORS AND REVIEWED BY THE CEO AND CFO PRIOR TO SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C EACH BOARD MEMBER SIGNS A CONFLICT OF INTEREST FORM ANNUALLY STATING THAT THEY WILL ABSTAIN FROM VOTING AND DISCUSSING ITEMS FOR WHICH THEY HAVE A CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15A THE BOARD OF DIRECTORS MEET ANNUALLY TO DISCUSS THE TERMS OF THE CEO'S CONTRACT. THEY USE DATA FROM THE LATEST IOWA HOSPITAL ASSOCIATION SALARY SURVEY. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART IX, LINE 11G ONCOLOGY FEES: PROGRAM SERVICE EXPENSES 199,638. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 199,638. RADIOLOGIST FEES: PROGRAM SERVICE EXPENSES 677,012. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 677,012. EMERGENCY ROOM FEES: PROGRAM SERVICE EXPENSES 279,221. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 279,221. OTHER FEES FOR SERVICES: PROGRAM SERVICE EXPENSES 1,842,770. MANAGEMENT AND GENERAL EXPENSES 200,456. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,043,226. FORM 990, PART XII, LINE 2C: THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND SELECTION OF THE INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PREVIOUS YEAR.