2015-05-13T06:45:42-05:00 2014-06-30 BKD LLP 910 E St Louis Street Suite 200 Springfield MO 65806 990 2013-07-01 232449454 Susquehanna Physician Services SUSQ 5703207900 1201 Grampian Boulevard Williamsport PA 17701 Charles J Santangelo Executive VP/CFO 5703213171 2015-05-13 1 Brian D Todd P00422601 4178658701 2013 2016-04-25 22:37:26Z Susquehanna Health Medical Group Steven P Johnson 777 Rural Avenue Williamsport PA 17701 82669831 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. 17 10 522 35 0 0 16375486 22039660 57437589 60630171 12673 0 0 0 73825748 82669831 0 0 0 0 58935460 66747134 0 0 0 16239361 16381217 75174821 83128351 -1349073 -458520 14521972 15522133 10272625 11731306 4249347 3790827 X Susquehanna Physician Services is a subsidiary of Susquehanna Health System(SHS). The mission of SHS 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 77914213 60630171 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, 2014there were approximately 745,092 patient visits for SPS. 77914213 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 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 522 0 0 0 0 0 0 0 0 0 0 0 X 17 10 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 0 0 0 PA X Management 5703268756 1201 Grampian Blvd Williamsport PA 17701 Ronald V DeFeo Jr Chairperson 1.00 1.00 X X 0 0 0 Ann S Pepperman Esquire Vice Chairperson 1.00 1.00 X X 0 0 0 Davie Jane Gilmour Ph D Secretary 1.00 1.00 X X 0 0 0 Sister Teresa Ann Jacobs Director 1.00 2.00 X 0 0 0 Leonard R Collins MD Director 40.00 3.00 X 246377 0 25959 Ronald E DiSimone MD Director 40.00 1.00 X 1111934 0 32145 Lynda Livingston Director 1.00 2.00 X 0 0 0 Timothy M Gage Dir Term End 12/2013 1.00 1.00 X 0 0 0 Daniel J Glunk MD Director 20.00 21.00 X 0 210233 30544 Steven P Johnson President/CEO 1.00 44.00 X X 0 539105 31861 Daniel A Klingerman Director 1.00 1.00 X 0 0 0 Philip H Johnson Director 1.00 2.00 X 0 0 0 James E Mothersbaugh Treasurer 1.00 1.00 X X 0 0 0 Alexander R Nesbitt MD Director 40.00 3.00 X 209772 0 28837 Kevin W Kist Jr DO Director 40.00 4.00 X 379149 0 32818 Robert DeCamp Director 1.00 3.00 X 0 0 0 Walter Laibinis Dir Term End 10/2013 1.00 42.00 X 0 252873 13806 Dr J Dennis Murray Director 1.00 2.00 X 0 0 0 Glenn Poirier Director 1.00 2.00 X 0 0 0 Charles J Santangelo Exec VP/CFO 1.00 40.00 X 0 338408 29440 Jan E Fisher Exec VP/C00 1.00 40.00 X 0 387968 19385 Ronald J Butler Exec VP/CBO 1.00 41.00 X 0 324224 15277 William C McCauley MD Sr. VP/President SPS 40.00 X 379609 0 30350 Edward G Wyshock MD Physician 40.00 X 1110549 0 29027 Warren L Robinson MD Physician 40.00 X 719071 0 10686 Sabrina Dowd Physician 40.00 X 690162 0 29952 David C Schaefer MD Physician 40.00 X 681263 0 18515 Michael V Hoffman MD Physician 40.00 X 656921 0 28845 6184807 2052811 407447 105 0 1 0 Comphealth Medical Staffing PO Box 972651 Dallas TX 75397 Temporary Employment 3773868 Linde Healthcare Staffing PO Box 915241 Dallas TX 75391 Temporary Employment 237788 Weatherby Locums PO Box 972633 Dallas TX 75397 Temporary Employment 161656 The Crimson Intiative PO Box 79461 Baltimore MD 21279 Decision Support 127900 4 22039660 22039660 Net Patient Services 621110 49724344 49724344 Inter-Entity SSA 621110 7235049 7235049 Other Revenue 621110 2765706 2765706 Inter-Entity Revenue 621110 474614 474614 Capitation Payments 621110 430458 430458 60630171 82669831 60630171 0 0 2476950 2066991 409959 55177090 52924295 2252795 1924526 1797420 127106 4396300 4113148 283152 2772268 2604656 167612 994323 994323 13925 13925 1382199 1382199 135445 135445 340026 253150 86876 699506 427406 272100 2779934 2407114 372820 102565 82785 19780 396119 338850 57269 222848 222848 931830 864397 67433 2244030 2243807 223 Provision For Bad Debt 2686747 2686747 Medical Supplies 2018956 2018956 Books Subscriptions Due 331129 287066 44063 Minor Equipment 243976 227104 16872 857659 815904 41755 83128351 77914213 5214138 0 828560 1192170 5780094 5789977 8969 0 884044 1185739 330853 251484 521093 577837 19350340 12857363 6147502 6492977 20857 20857 11092 14521972 15522133 9472625 5445506 3204656 800000 3081144 10272625 11731306 X 4249347 3790827 4249347 3790827 14521972 15522133 -458520 0 X 1 X 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 41973 41973 373321 373082 239 2223935 1297961 925974 12355996 9992082 2363914 4355115 1194238 3160877 6492977 Third Party Payors 800000 Due To Affliates 2281144 3081144 57943424 -2686747 -2686747 60630171 22039660 22039660 82669831 80441604 0 80441604 2686747 2686747 83128351 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 -$2,686,747 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 $10,789,379 Divine Providence Hospital $7,896,720 and Muncy Valley Hospital $3,353,561. Part XIII Line 4b - Provision for doubtful accounts of $2,686,747 are not included in expenses on the audited financial statements. Central America Program Services Captive insurance company 2244030 0 0 0 0 0 0 2244030 0 2244030 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 Leonard R Collins MD Director 243795 0 0 0 2582 0 9410 0 16549 0 272336 0 0 0 Ronald E DiSimone MD Director 897427 0 209482 0 5025 0 9650 0 22495 0 1144079 0 0 0 Daniel J Glunk MD Director 0 208983 0 0 0 1250 0 10560 0 19984 0 240777 0 0 Steven P Johnson President/CEO 0 524745 0 0 0 14360 0 13475 0 18386 0 570966 0 0 Alexander R Nesbitt MD Director 177978 0 5618 0 26176 0 11553 0 17284 0 238609 0 0 0 Kevin W Kist Jr DO Director 321749 0 2313 0 55087 0 9650 0 23168 0 411967 0 0 0 Walter Laibinis Dir Term End 10/2013 0 182813 0 70060 0 0 0 6069 0 7737 0 266679 0 0 Charles J Santangelo Exec VP/CFO 0 331702 0 0 0 6706 0 9650 0 19790 0 367848 0 0 Jan E Fisher Exec VP/C00 0 383073 0 0 0 4895 0 9650 0 9735 0 407353 0 0 Ronald J Butler Exec VP/CBO 0 320062 0 0 0 4162 0 9650 0 5627 0 339501 0 0 William C McCauley MD Sr. VP/President SPS 376409 0 0 0 3200 0 9650 0 20700 0 409959 0 0 0 Edward G Wyshock MD Physician 397871 0 660023 0 52655 0 9650 0 19377 0 1139576 0 0 0 Warren L Robinson MD Physician 401794 0 264993 0 52284 0 9650 0 1036 0 729757 0 0 0 Sabrina Dowd Physician 616116 0 69291 0 4755 0 9650 0 20302 0 720114 0 0 0 David C Schaefer MD Physician 622899 0 4250 0 54114 0 9650 0 8865 0 699778 0 0 0 Michael V Hoffman MD Physician 612299 0 40090 0 4532 0 9650 0 19195 0 685766 0 0 0 Part I, Line 6 In order for the Leadership Team to participate in the annual variable compensation program (VCIP), a minimum operating margin must be achieved for the most recently completed year on a consolidated, system-level basis. Individual goals & objectives related to the VCIP may also include individual entity operarating performance. Form 990, Part VI, Section A, line 6 Susquehanna Health System, EIN #23-2751183, is the sole member of the governing body Form 990, Part VI, Section A, line 7a Susquehanna Health System, 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 (Susquehanna Health System, 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. Form 990, Part V, Line 1a Number reported in Box 3 of Form 1096 All 1099's are issued by Susquehanna Health System EIN #23-2751183. All expenses are then allocated back to all related entities. Form 990, Part V, Line 2a & 2b Number of employees reported on Form W-3 Susquehanna Health System EIN #23-2751183 utilizes a common paymaster which includes the following entities: Divine Providence Hospital #24-0799343 Muncy Valley Hospital #24-0806023 The Williamsport Hospital #24-0795508 Susquehanna Health Foundation #23-2743470 Susquehanna Physician Services #23-2449454 Susquehanna Ventures Inc #23-2470263 Williamsport Area Ambulance Service Cooperative #23-2416166 The total number of employees reported on Form W-3 would be 3,500 for Susquehanna Health System #23-2751183. Of that total, 522 employees payroll expenses were recorded by Susquehanna Physician Services #23-2449454. The Williamsport Hospital 777 Rural Avenue Williamsport PA 17701 240795508 Hospital PA 501 (c) (3) Line 3 Susquehanna Health System 0 Divine Providence Hospital 1100 Grampian Blvd Williamsport PA 17701 240799343 Hospital PA 501 (c) (3) Line 3 Susquehanna Health System 0 Muncy Valley Hospital 215 East Water Street Muncy PA 17756 240806023 hospital PA 501 (c) (3) Line 3 Susquehanna Health System 0 Susquehanna Health Foundation 1100 Grampian Blvd Williamsport PA 17701 232743470 Fundraising and affiliated activities PA 501 (c) (3) Line 11a, I Susquehanna Health System 0 Susquehanna Health System 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 0 Soliders & Sailors Memorial Hospital 32-36 Central Avenue Wellsboro PA 16901 232176963 Hospital PA 501 (c) (3) Line 3 Susquehanna Health System 0 The Green Home 37 Central Ave Wellsboro PA 16901 240804365 Skilled nursing & assisted living PA 501 (c) (3) Line 9 Susquehanna Health System 0 Tioga Health Care Partners 15 Meade Street Wellsboro PA 16901 251765538 Physician Services PA 501 (c) (3) Line 11b, II Susquehanna Health System 0 Laurel Management Services 15 Meade Street Wellsboro PA 16901 251644910 Mgmt consulting & supervisory services PA 501 (c) (3) Line 11b, II Susquehanna Health System 0 Laurel Realty 15 Meade Street wellsboro PA 16901 231403678 Own & manage real estate PA 501 (c) (2) N/A Susquehanna Health System 0 Laurel Health System 15 Meade Street Wellsboro PA 16901 240795488 Coordinate & manage the delivery of healthcare PA 501 (c) (3) Line 11b, II Susquehanna Health System 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 Community Basket LLC 1205 Grampian Blvd Williamsport PA 17701 201195739 Rents real estate PA N/A excluded from tax 0 0 Susquehanna Ventures 1201 Grampian Blvd Williamsport PA 17701 232470263 Pharmacy and infusion services PA N/A C 0 Susquehanna Health System Insurance Network LTD PO Box 1159 Grand Caymans CJ KY1-1102 980458722 Captive insurance company CJ Susquehanna Health System 0 Tyoga Carenet 15 Meade Street Wellsboro PA 16901 251810967 Integrate Health Care PA N/A C 0 Tioga Management Services Org 15 Meade Street Wellsboro PA 16901 232886336 Manage Physician Practices PA N/A C 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 0 0 0 0