2015-06-15T10:15:33-05:00 2014-07-31 390758449 WIPFLI LLP PO BOX 8010 WAUSAU WI 544028010 990 2013-08-01 391139101 ROGERS MEMORIAL HOSPITAL INC ROGE 2626463526 34700 VALLEY ROAD OCONOMOWOC WI 53066 KEITH DEGNER EXECUTIVE VICE PRESIDENT AND CFO 2626463526 2015-06-10 1 Kimberly Heller CPA P00766668 7158453111 2015-06-10 2013 2016-02-25 16:41:14Z KEITH DEGNER 34700 VALLEY ROAD OCONOMOWOC WI 53066 103976152 0 X WWW.ROGERSHOSPITAL.ORG X 1907 WI ROGERS MEMORIAL HOSPITAL, INC. OPERATES FACILITIES IN OCONOMOWOC, MILWAUKEE, KENOSHA, AND BROWN DEER, WISCONSIN TO PROVIDE INPATIENT AND OUTPATIENT PSYCHIATRIC SERVICES TO PATIENTS PRIMARILY FROM THE MIDWEST. SERVICES AVAILABLE AT THE HOSPITAL INCLUDE PROGRAMS RELATING TO THE RECOVERY FROM ADDICTIONS; TREATMENT FOR DISRUPTIVE BEHAVIOR OF CHILDREN AND ADOLESCENTS; GENERAL PSYCHIATRY FOR ADULTS; REGIONAL ADULT AND ADOLESCENT PARTIAL HOSPITALIZATION; AND CHILD AND ADOLESCENT EXTENDED CARE. 12 4 1229 0 1264481 -298402 779699 155307 92355717 100008194 682142 1055401 10150 -975530 93827708 100243372 540183 1978365 0 0 51617440 60325067 0 0 0 25420683 26672646 77578306 88976078 16249402 11267294 137569184 150863373 42687241 43134538 94881943 107728835 X WE EXIST TO OFFER EXEMPLARY BEHAVIORAL HEALTHCARE SERVICES, INCLUDING TREATMENT, RESEARCH, EDUCATION, TRAINING AND CONSULTATION BUILT ON OUR CENTURY-LONG HERITAGE. WE ARE DEDICATED TO THE DELIVERY OF QUALITY CARE USING A SKILLED TEAM APPROACH THAT RESPECTS THE DIGNITY OF EACH INDIVIDUAL. OUR SUCCESS IS DEMONSTRATED IN PREMIER QUALITY CARE, SUCCESSFUL OUTCOM, FINANCIAL INTEGRITY, PERSONAL AND ORGANIZATIONAL GROWTH, AND COMMUNITY WELL-BEING. 0 0 69605170 1978365 98557631 ROGERS MEMORIAL HOSPITAL, INC.PRIAMARY EXEMPT PURPOSE AND PROGRAM ACCOMPLISHMENTSROGERS MEMORIAL HOSPITAL, INC. (ROGERS) IS A TAX-EXEMPT HOSPITAL WHICH EXISTS TO OFFER EXEMPLARY BEHAVIORAL HEALTHCARE SERVICES, INCLUDING TREATMENT, RESEARCH, EDUCATION AND TRAINING, IN CONTINUATION OF A CENTURY LONG TRADITION. ROGERS IS DEDICATED TO A SKILLED, PROFESSIONAL, TEAM APPROACH OF INDIVIDUALIZED CARE WITHIN A TREATMENT COMMUNITY, RESPECTING THE DIGNITY OF EACH PERSON.ROGERS IS GOVERNED BY A VOLUNTEER CITIZEN BOARD OF DIRECTORS AND IS STAFFED BY HIGHLY QUALIFIED MENTAL HEALTH PROFESSIONALS INCLUDING TEAMS OF PHSICIANS, THERAPISTS, COUNSELORS, DIETICIANS, AND OTHER PROFESSIONAL STAFF. ROGERS HAS DEVELOPED COMMUNITY GOODWILL AND CONFIDENCE THROUGH STABLE OWNERSHIP AND GOVERNANCE STRUCTURES.TO MEET THE INDIVIDIAUL NEEDS OF PATIENTS, ROGERS OFFERS THE FOLLOWING THREE LEVELS OF CARE:INPATIENT CARE - THIS INTENSIVE, SHORT-TERM LEVEL OF CARE PROVIDES STABILIZATION FOR A VARIETY OF ACUTE PSYCHIATRIC SYMPTOMS AND DIAGNOSES. THE PRIMARY FOCUS IS ASSESSMENT, STABILIZATION AND TRANSITION INTO PARTIAL HOSPITALIZATION (DAY TREATEMENT) OR OUTPATIENT THERAPY.PARTIAL HOSPITALIZATION - PARTIAL HOSPITALIZATION PROGRAMS PROVIDE TRANSITION FROM INPATIENT CARE, AN ALTERNATIVE TO INPATIENT TREATMENT, OR A SUPPLEMENT TO OUTPATIENT THERAPY. THESE HALF-DAY OR PART-TIME STRUCTURED PROGRAMS ALLOW PATIENTS TO CONTINUE INVOLVEMENT AT HOME, WORK, OR SCHOOL.RESIDENTIAL TREATMENT - RESIDENTIAL TREATMENT CENTERS PROVIDE INTENSIVE EXTENDED CARE OPPORTUNITIES IN A HOME-LIKE SETTING FOR INDIVIDUALS SEEKING TO OVERCOME SEVERE EATHING DISORDERS, ALCOHOL AND OTHER ADDITIONS, AND OBSESSIVE-COMPULSIVE DISORDER. LOCATED AT OUR OCONOMOWOC SITE ON 80 ACRES OF WOODED LAKEFRONT PROPERTY, EACH CENTER PROVIDES A CALMING, CONFIDENTIAL ENVIRONMENT THAT ALLOWS PATIENTS TO FOCUS ON THEIR TREATMENT. OUR RESIDENTIAL PROGRAMS ARE TYPICALLY ONE-THIRD THE DAILY RATE OF INPATIENT CARE, WHILE PROVIDNG INPATIENT-INTENSIVE TREATMENT. IN 2014, ROGERS PATIENT CARE SERVICES INCLUDED 42,577 INPATIENT DAYS, 57,782 PARTIAL TREATMENT DAYS, AND 34,083 RESIDENTIAL PROGRAM DAYS. 69605170 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 0 1 92 0 0 1229 1 1 1 0 0 0 0 0 0 0 0 0 X 12 4 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 0 1 1 0 WI X KEITH DEGNER 2626464605 34700 VALLEY ROAD OCONOMOWOC WI 53066 Garry Anderson Chair 3.00 X X 0 0 0 Peter Gottsacker Board Member 1.00 X 0 0 0 Mark Mohr Treasurer 3.00 X X 0 0 0 Roger Jensen Board Member 1.00 X 0 0 0 Mary Panzer Board Secretary 3.00 X X 0 0 0 John Curran Board Member 1.00 X 0 0 0 Gary Jorgensen Board Member 1.00 X 0 0 0 William Mulligan Board Member 1.00 X 0 0 0 Theodore Weltzin Board Member 1.00 X 403680 0 33961 Patrick Andritsch Board Member 1.00 X 0 0 0 Ted Garvey Board Member 1.00 X 0 0 0 Vineet Kulkarni Board Member 1.00 X 305421 0 27095 Keith Degner CFO 40.00 X 220351 0 30640 Patrick Hammer CEO 10.00 30.00 X 0 607015 43659 Gerald Noll EXECUTIVE VICE PRESIDENT 10.00 30.00 X 0 391329 29415 Paul Mueller COO 40.00 X 357819 0 39586 William Hendricks VP Operations 40.00 X 348648 0 36478 Renee Patterson VP of Employment & Trainin 40.00 X 225552 0 34569 Teresa Schultz VP Nursing 40.00 X 213955 0 8529 Peter Lake Medical Director 40.00 X 466472 0 41086 Kambiz Pahlavan Medical Director 40.00 X 281140 0 12700 Ahmed Numaan Physician 40.00 X 407756 0 10200 Bradley Riemann Physician 40.00 X 328511 0 35765 Michael Miller Physician 40.00 X 320969 0 34675 Brad Smith Physician 40.00 X 358844 0 35765 Roger Luhn Physician 40.00 X 324535 0 39586 David Moulthrop Former CEO 1.00 X 230526 0 27612 4794179 998344 521321 64 1 1 0 WIPFLI LLP 11 SCOTT STREET WAUSAU WI 54403 ACCOUNTING 565419 HALL RENDER KILLIAN HEATH & LYMAN P 39778 TREASURY CENTER CHICAGO IL 60694 ATTORNEY 307998 TRAINING INSTITUTE FOR SUICIDE ASSESSMEN 104 STONEY BROOK ROAD NEWBURY NH 03255 CONSULTING 146468 JERI DAVIS INTERNATIONAL LLC PO BOX 770534 MEMPHIS TN 38177 CONSULTING 144105 THE JOXEL GROUP LLC 10555 N PORT WASHINGTON RD SUITE 20 MEQUON WI 53092 CONSULTING 141840 7 155307 155307 NET PATIENT SVC REVENUE 900099 98638486 98515025 123461 MANAGEMENT SERVICES 541610 1264481 1264481 CAFETERIA 900099 62621 62621 PARTNERS IN BEHAVIORAL HEALTH 900003 42606 42606 100008194 496597 496597 69650 0 69650 69650 69650 4291584 3732780 558804 558804 558804 WRITE-OFF DEFERRED FINANCING COST 900000 -1045180 -1045180 -1045180 100243372 98557631 1264481 265953 1978365 1978365 2334389 1023882 1310507 47411769 39266046 8145723 1301440 1081451 219989 6082343 4990302 1092041 3195126 2580908 614218 6099004 3708949 2390055 1710159 1355185 354974 1211463 699311 512152 668057 581210 86847 4611777 4012246 599531 964467 839086 125381 PROFESSIONAL AND CONTRA 7038904 3217997 3820907 BAD DEBT EXPENSE 3958585 3958585 PROPERTY TAXES 241198 241198 DUES AND FEES 169032 70449 98583 88976078 69605170 19370908 0 1921411 791931 22886144 15027967 13779104 15271401 711065 276855 124010860 32644574 71167122 91366286 22423776 25379958 4680562 2748975 137569184 150863373 8557485 10448890 31901668 30390000 585000 2228088 1710648 42687241 43134538 X 91978379 105122379 1752514 889477 1151050 1716979 94881943 107728835 137569184 150863373 X 11267294 583537 996061 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 92174 92174 0 Part II-B, Line 1: PORTIONS OF ASSOCIATION DUES ALLOCATED FOR LOBBYING EXPENSES OF WHA $15,914(11.5%) AND AMA $16,260 (23.98%). WE HIRED AN INDIVIDUAL WHO COMMUNICATED TO LEGISLATORS. THE INDIVIDUAL WORKED ON THE SPEAKERS BEHAVIORAL HEALTH TASK FORCE, AND THE DEVELOPMENT OF A PROPOSAL TO CREATE A PROFESSIONALS HEALTH PROGRAM. 1263229 565929 94384 1923542 578612 596745 87872 1263229 1268341 308852 1419 1000000 578612 1000000 245453 22888 1268341 1000000 1000000 0.89260 0.10740 0 1 1 5070341 5070341 86493214 20837895 65655319 3064610 339592 2725018 17741094 8810004 8931090 11641601 2657083 8984518 91366286 EST. THIRD PARTY SETTLEMENTS 596813 DEFERRED COMPENSATION 771281 DUE TO ROGERS BEHAVIORAL HEALTH SYSTEM, INC. 249403 Due to Rogers InHealth, Inc. 93151 1710648 X 96284787 -3958585 -3958585 100243372 0 100243372 85017493 0 85017493 3958585 3958585 88976078 Part V, Line 4: ROGERS MEMORIAL HOSPITAL'S ENDOWMENT IS INTENDED TO PROVIDE FUNDS FOR FUTURE PROGRAMS AND CAPITAL IMPROVEMENTS. Part X, Line 2: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE HOSPITAL DETERMINES WHETHER IT IS MORE-LIKELY-THAN-NOT THAT A TAX POSITION WITLL BE SUSTAINED UPON EXAMINATION BY THE TAXING AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITIONS, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THE TAX POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE HOSPITAL HAS NOT RECORDED ANY ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS AS OF JULY 31, 2014 AND 2013. THE FEDERAL AND STATE RETURNS FOR TAX YEARS 2010 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE AND STATE AUTHORITIES. Part XI, Line 2d - Other Adjustments: BAD DEBT EXPENSE -3,958,585. Part XII, Line 4b - Other Adjustments: BAD DEBT EXPENSE 3,958,585. 1 1 X 1 X 115.000000000000 1 X 115.000000000000 1 1 1 0 1 1 506026 506026 0.00570 25155710 22596086 2559624 0.02880 25661736 22596086 3065650 0.03450 180711 107393 73318 0.00080 192367 192367 0.00220 373078 107393 265685 0.00300 26034814 22703479 3331335 0.03750 1 1901133 2733956 3107322 -373366 X 0 2 1 ROGERS MEMORIAL HOSPITAL - OCONOMOWOC 34700 VALLEY ROAD OCONOMOWOC WI 53006 X 2 ROGERS MEMORIAL HOSPITAL - WEST ALLIS 11101 W LINCOLN AVENUE MILWAUKEE WI 53227 X ROGERS MEMORIAL HOSPITAL - OCONOMOWOC 1 1 X X X X X X X X X 13 1 0 1 X SEE PART V, SECTION B, LINE 5D X X X X X X X 0 0 1 1 115.000000000000 1 115.000000000000 1 X X X X X X X 1 1 X X 1 X 0 1 X 0 0 ROGERS MEMORIAL HOSPITAL - WEST ALLIS 2 1 X X X X X X X X X 13 1 0 1 X SEE PART V, SECTION B, LINE 5D X X X X X X X 0 0 1 1 115.000000000000 1 115.000000000000 1 X X X X X X X 1 1 X X 1 X 0 1 X 0 0 ROGERS MEMORIAL HOSPITAL - OCONOMOWOC Part V, Section B, Line 5d: http://rogershospital.org/pdf/CHNA-2013.pdf ROGERS MEMORIAL HOSPITAL - WEST ALLIS Part V, Section B, Line 5d: http://rogershospital.org/pdf/CHNA-2013.pdf ROGERS MEMORIAL HOSPITAL - OCONOMOWOC Part V, Section B, Line 7: The advisory committee made the decision not to address the following priorities:1. Community Support GroupsThe advisory committee felt that there are a wide variety of support groups for AODA and mental health disorders already located in each county in Southeastern Wisconsin. Several of them are handled through the county level. In order to prevent duplication RMH will not respond to this priority at this time.2. Knowing Where to go for HelpThere is currently a program in Waukesha called 211/First Call for Help that provides immediate support and connections to community resources for individuals and families of several South Eastern Wisconsin. This need has started being addressed at the county level therefore, Rogers will not respond to this priority at this time. ROGERS MEMORIAL HOSPITAL - WEST ALLIS Part V, Section B, Line 7: The advisory committee made the decision not to address the following priorities:1. Community Support GroupsThe advisory committee felt that there are a wide variety of support groups for AODA and mental health disorders already located in each county in Southeastern Wisconsin. Several of them are handled through the county level. In order to prevent duplication RMH will not respond to this priority at this time.2. Knowing Where to go for HelpThere is currently a program in Waukesha called 211/First Call for Help that provides immediate support and connections to community resources for individuals and families of several South Eastern Wisconsin. This need has started being addressed at the county level therefore, Rogers will not respond to this priority at this time. ROGERS MEMORIAL HOSPITAL - OCONOMOWOC Part V, Section B, Line 14g: NOTIFIED INDIVIDUALS IN COMMUNICATIONS REGARDING THEIR BILLS. ROGERS MEMORIAL HOSPITAL - WEST ALLIS Part V, Section B, Line 14g: NOTIFIED INDIVIDUALS IN COMMUNICATIONS REGARDING THEIR BILLS. ROGERS MEMORIAL HOSPITAL - OCONOMOWOC Part V, Section B, Line 20d: THE HOSPITAL USES VARIOUS RATES DEPENDING ON EACH PATIENTS UNIQUE SITUATIONS, BASED ON THE CRITERIA FILLED OUT ON OUR FINANCIAL ASSISTANCE FORM. ROGERS MEMORIAL HOSPITAL - WEST ALLIS Part V, Section B, Line 20d: THE HOSPITAL USES VARIOUS RATES DEPENDING ON EACH PATIENTS UNIQUE SITUATIONS, BASED ON THE CRITERIA FILLED OUT ON OUR FINANCIAL ASSISTANCE FORM. 3 ROGERS MEMORIAL HOSPITAL - MADISON 406 SCIENCE DRIVE SUITE 110 MADISON WI 53711 CENTER FOR EATING AND ANXIETY DISORDERS, AND COGNITIVE-BEHAVIORAL THERAPY ROGERS MEMORIAL HOSPITAL - BROWN DEER 4600 WEST SHROEDER DRIVE SUITE 2 BROWN DEER WI 53223 TREATMENT CENTER FOR CHILDREN AND ADOLESCENTS ROGERS MEMORIAL HOSPITAL - KENOSHA 9916 75TH STREET KENOSHA WI 53142 TREATMENT CENTER FOR CHILDREN AND ADOLESCENTS Part I, Line 6a: COMMUNITY BENEFIT WISCONSIN STATE ASSOCIATION SURVEY Part I, Line 7: LINES A - E: CONSISTENT WITH THE MISSION OF THE HOSPITAL, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY, INCLUDING PROVIDING SERVICES TO THOSE PERSONS WHO ARE UNINSURED AND WHO CANNOT AFFORD HEALTH INSURANCE BECAUSE OF INADEQUATE RESOURCES. THE HOSPITAL PROVIDES DISCOUNTS FROM ESTABLISHED CHARGES TO SELF-PAY PATIENTS WITHOUT REGARD TO THE PATIENT'S ABILITY TO PAY AND CONSIDERS THESE DISCOUNTS A PART OF THEIR COMMUNITY BENEFIT. PATIENTS WHO MEET CERTAIN CRITERIA FOR COMMUNITY CARE, GENERALLY BASED ON FEDERAL POVERTY GUIDELINES, ARE PROVIDED CARE WITHOUT CHARGE OR AT A REDUCED RATE, DETERMINED BASED ON QUALIFYING CRITERIA AS DEFINED IN THE HOSPITAL'S COMMUNITY CARE POLICY AND FROM APPLICATIONS COMPLETED BY PATIENTS AND THEIR FAMILIES. LINE H: RESEARCH AND RELATED COSTS ARE DIRECTLY ASSIGNED BASED ON UTILIZATION OF RESOURCES.LINES E AND I: THESE ARE COSTS DEVELOPED BASED ON THE ESTIMATED TIME AND RESOUCES UTILIZED IN PROVIDING THESE COMMUNITY BENEFITS. Part III, Line 4: ROGERS MEMORIAL HOSPITAL UTILIZED A COST TO CHARGE RATIO FOR DETERMINING COST OF BAD DEBT EXPENSE.THE CARRYING AMOUNTS OF PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY ALLOWANCES THAT REFLECT MANAGEMENT'S BEST ESTIMATE OF THE AMOUNTS THAT WILL NOT BE COLLECTED. MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH A CHARGE TO GROSS REVENUE AND A CREDIT TO PATIENT ACCOUNTS RECEIVABLE. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY FROM UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER MANAGEMENT HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO PATIENT ACCOUNTS RECEIVABLE.CERTAIN AMOUNTS OF BAD DEBT EXPENSE COULD BE ATTRIBUTED TO CHARITY CARE AS ALL RELEVANT INFORMATION IS NOT READILY AVAILABLE FOR ALL PATIENTS. IF, AT THE TIME OF ADMISSION AND BEFORE BILLING, PATIENTS WHO KNEW THEY COULD NOT PAY FOR SERVICES REQUESTED ASSISTANCE UP FRONT OR THE HOSPITAL BECAME AWARE UPON ADMISSION THAT A PATIENT WOULD BE UNABLE TO PAY, THEY WOULD HAVE HAD THOSE PATIENTS APPLY FOR CHARITY CARE INSTEAD OF HAVING THE FACTS COME TO LIGHT AFTER THE PATIENT HAD BEEN BILLED AND NOT BEEN ABLE TO PAY. Part III, Line 8: DATA REPORTED AS MEDICARE ALLOWABLE COSTS WERE TAKEN DIRECTLY FROM THE MEDICARE COST REPORT.THE MEDICARE SHORTFALL SHOULD BE CONSIDERED A COMMUNITY BENEFIT AS A HOSPITAL THAT SERVES PATIENTS WITH GOVERNMENT HEALTH BENEFITS (INCLUDING MEDICARE) INDICATES THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY AND THEREFORE IMPLIES THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT. Part III, Line 9b: ROGERS MEMORIAL HOSPITAL RECOGNIZES THE NEED FOR THE MEDICALLY INDIGENT TO RECEIVE NECESSARY SERVICES. PATIENT CARE IS NOT AFFECTED BY HIS/HER INABLILITY TO PAY REGARDLESS OF FINANCIAL STATUS, RACE, COLOR, CREED, SEXUAL ORIENTATION, HANDICAP, SEX OR NATIONAL ORIGIN. SERVICES ARE RENDERED IN A CARING, RESPECTFUL AND CONCERNED MANNER. TO ENSURE THAT THE PHILOSOPHY OF THE HOSPITAL IS UPHELD, A CONSISTENT METHOD OF DETERMINING ELIGIBILITY FOR COMMUNITY CARE HAS BEEN DEVELOPED. IT IS THE POLICY OF ROGERS MEMORIAL HOSPITAL TO WRITE-OFF ACCOUNTS THAT QUALIFY FOR CHARITY CARE, THUS THERE ARE NO COLLECTION EFFORTS RELATED TO THOSE THAT QUALIFY FOR CHARITY CARE. COMMUNITY CARE IS NOT TO BE USED AS A SUBSTITUTE FOR BAD DEBT. ONLY THOSE PATIENTS WHO MEET THE CRITERIA ARE ELIGIBLE FOR COMMUNITY CARE RELIEF. THOSE PATIENTS WHO DO NOT MEET THE CRITERIA AND REFUSE TO COOPERATE WITH COLLECTION EFFORTS WILL BE PURSUED TO THE EXTENT DEEMED NECESSARY BY MANAGEMENT FOR COLLECTION AND IF STILL UNCOLLECTIBLE, WILL BE WRITTEN OFF TO BAD DEBT. Part VI, Line 2: WE COLLABORATE WITH OTHER PROVIDERS THROUGH PARTNERSHIPS AND CONSULTING RELATIONSHIPS WITH THE MEDICAL COLLEGE OF WISCONSIN, CHILDREN'S HOSPITAL OF WISCONSIN, FROEDTERT HEALTH, COMMUNITY MEMORIAL HOSPITAL AND COLUMBIA ST. MARY'S,IN ORDER TO BRING QUALITY BEHAVIORAL HEALTH SERVICES TO WISCONSIN RESIDENTS. Part VI, Line 3: A PATIENT'S ABILITY TO PAY FOR SERVICES WILL BE DETERMINED UPON, OR AS SOON AS POSSIBLE AFTER, ADMISSION TO THE HOSPITAL. A.) IF, UPON ADMISSION (INPATIENT, OUTPATIENT), THE PATIENT AND/OR RESPONSIBLE PARTY REQUESTS FINANCIAL ASSISTANCE, HE/SHE WILL BE INFORMED THAT THE HOSPITAL HAS A COMMUNITY CARE POLICY AND WILL BE REFERRED TO THE MANAGER OF PATIENT ACCOUNTS BY THE ADMITTING SPECIALIST. B.) IF, AFTER ADMISSION, THE PATIENT IS DETERMINED TO BE POSSIBLY ELIGIBLE FOR COMMUNITY CARE AND REQUESTS ASSISTANCE, HE/SHE WILL BE REFERRED TO THE MANAGER OF PATIENT ACCOUNTS BY THE BILLING ASSISTANT. Part VI, Line 4: ROGERS MEMORIAL HOSPITAL OPERATES FACILITIES IN THE WISCONSIN COMMUNITIES OF ONCONOMOWOC, WEST ALLIS, BROWN DEER, KENOSHA, AND DELAFIELD TO PROVIDE INPATIENT AND OUTPATIENT BEHAVIORAL HEALTH AND PSYCIATRIC SERVICES TO PATIENTS PRIMARILY FROM THE MIDWEST. THE HOSPITAL PROVIDES SERVICES RELATING TO RECOVERY FROM ADDICTIONS, ABUSE, DISRUPTIVE BEHAVIOR, EATING AND OBSESSIVE COMPULSIVE DISORDERS; GENERAL PSYCHIATRY FOR ADULTS, ADOLESCENTS, AND CHILDREN; AND ADOLESCENT EXTENDED CARE.IN 2010-2011, APPROXIMATELY 8,000 INDIVIDUALS WERE ADMITTED TO ROGERS. OF THE 72 WISCONSIN COUNTIES, RESIDENTS FROM 55 OF THESE COUNTIES RECEIVED SERVICES AT ROGERS. MILWAUKEE AND WAUKESHA COUNTY RESIDENTS CONSTITUTED OVER 60% OF THE POPULATION SERVED, WHILE 30% WERE FROM OTHER WISCONSIN COUNTIES. THIS SERVICES AREA SUGGESTS THAT ROGERS NOT ONLY PROVIDES A SIGNIFICANT SERVICE TO ITS SURROUNDING COMMUNITY, BUT ALSO TO THE GREATER WISCONSIN COMMUNITY AS A WHOLE. Part VI, Line 5: SEE STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS ON PART III OF FORM 990. 1 ROGERS MEMORIAL HOSPITAL FOUNDATION INC 34700 VALLEY ROAD OCONOMOWOC WI 53066 391363507 501(C)3 934738 547360 Cost PROVIDES SUPPORT TO FOUNDATION TO ASSIST IN CARRYING OUT IT'S EXEXPT PURPOSE THE HOSPITAL PROVIDES SUPPORT TO THE FOUNDATION TO ASSIST IN CARRYING OUT IT'S EXEXPT PURPOSE ROGERS INHEALTH INC 34700 VALLEY ROAD OCONOMOWOC WI 53066 463960059 501(C)3 496267 Cost PROVIDES SUPPORT TO INHEALTH TO ASSIST IN CARRYING OUT IT'S EXEXPT PURPOSE THE HOSPITAL PROVIDES SUPPORT TO INHEALTH TO ASSIST IN CARRYING OUT IT'S EXEXPT PURPOSE 2 Part I, Line 2: AS GRANTS ARE MADE PRIMARILY TO ROGERS MEMORIAL HOSPITAL FOUNDATION, MONITORING OF THESE TRANSACTIONS ARE PERFORMED BY OFFICERS OF THE HOSPITAL WITH OVERSIGNT BY THE BOARD OF DIRECTORS. X 1 1 X X X X X 0 0 0 0 0 0 0 0 0 Theodore Weltzin Board Member 402132 0 0 0 1548 0 10200 0 23761 0 437641 0 0 0 Vineet Kulkarni Board Member 303363 0 0 0 2058 0 10200 0 16895 0 332516 0 0 0 Keith Degner CFO 191081 0 27225 0 2045 0 0 0 30640 0 250991 0 0 0 Patrick Hammer CEO 0 510683 0 87504 0 8828 0 10200 0 33459 0 650674 0 0 Gerald Noll EXECUTIVE VICE PRESIDENT 0 326658 0 63935 0 736 0 10200 0 19215 0 420744 0 0 Paul Mueller COO 310144 0 44752 0 2923 0 10200 0 29386 0 397405 0 0 0 William Hendricks VP Operations 304006 0 42235 0 2407 0 10200 0 26278 0 385126 0 0 0 Renee Patterson VP of Employment & Trainin 200808 0 24474 0 270 0 9004 0 25565 0 260121 0 0 0 Teresa Schultz VP Nursing 190337 0 22898 0 720 0 8529 0 0 0 222484 0 0 0 Peter Lake Medical Director 460819 0 0 0 5653 0 10200 0 30886 0 507558 0 0 0 Kambiz Pahlavan Medical Director 275850 0 0 0 5290 0 10200 0 2500 0 293840 0 0 0 Ahmed Numaan Physician 407293 0 0 0 463 0 10200 0 0 0 417956 0 0 0 Bradley Riemann Physician 328020 0 0 0 491 0 10200 0 25565 0 364276 0 0 0 Michael Miller Physician 318762 0 0 0 2207 0 10200 0 24475 0 355644 0 0 0 Brad Smith Physician 357678 0 0 0 1166 0 10200 0 25565 0 394609 0 0 0 Roger Luhn Physician 318360 0 0 0 6175 0 10200 0 29386 0 364121 0 0 0 David Moulthrop Former CEO 132808 0 96346 0 1372 0 10200 0 17412 0 258138 0 0 0 Part I, Line 1a HEALTH AND SOCIAL MEMBERSHIPS FOR CERTAIN OFFICERS, KEY EMPLOYEES AND HIGHEST COMPENSATED INDIVIDUALS ARE INCLUDED IN TAXABLE COMPENSATION AS THESE FEES ARE PAID BY ROGERS MEMORIAL HOSPITAL. $3,470 PAUL MUELLER $3,470 PAT HAMMER A WISCONSIN HEALTH AND EDUCATION FACILITIES AUTHORITY 391337855 97710VVT2 2004-09-23 5135000 CONSTRUCTION OF AN ADDITION TO BORROWERS MENTAL HEALTH HOSPITAL FACILITY 0 0 0 B COMMUNITY DEVELOPMENT AUTHORITY OF THE CITY OF WEST ALLIS 396005651 951175AA6 2008-07-01 10000000 BUILDING IMPROVEMENTS TO THE BORROWER'S MENTAL HEALTH HOSPITAL FACILITY 0 0 0 C COMMUNITY DEVELOPMENT AUTHORITY OF THE VILLIAGE OF SUMMIT 396006129 866334AA3 2011-05-31 15000000 BUILDING IMPROVEMENTS TO THE OCONOMOWOC SITE 0 0 0 A 760000 5135000 102701 5096488 2005 0 0 1 1 B 2070000 10000000 356485 9643515 2009 0 0 1 1 C 1390000 15000000 302624 14697376 2013 0 0 1 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 C 0 0 0 0 0 0 0 A 0 0 0 0 1 0 0 0 0 B 0 0 0 0 0 0 0 0 0 C 0 0 0 0 0 0 0 0 0 A 0 B 0 C 0 RW BAIRD GARRY ANDERSON, BOARD CHAIRMAN, IS BAIRD'S SENIOR VP OF INVESTMENTS 230135 ROGER'S MEMORIAL HOSPITAL PAYS FEES TO BAIRD FOR INVESTMENT SERVICES. 0 VJS CONSTRUCTION SERVICES GARY JORGENSEN, A BOARD MEMBER, IS THE CHAIRMAN OF VJS CONSTRUCTION 9020044 ROGER'S MEMORIAL HOSPITAL HAS CONTRACTED WITH VJS FOR CONSTRUCTION AND CONSTRUCTION MANAGEMENT SERVICES. 0 TWP ARCHITECTURE JOHN CURRAN, A BOARD MEMBER, IS THE SENIOR VP OF TWP ARCHITECTURE 749300 TWP ARCHITECTURE PROVIDES ARCHITECTURAL SERVICES TO ROGER'S MEMORIAL HOSPITAL. 0 PANZER PUBLIC AFFAIRS MARY PANZER, BOARD MEMBER 60000 PANZER PUBLIC AFFAIRS COMMUNICATES WITH LEGISLATORS, WORKS ON SPEAKERS BEHAVIORAL TASK FORCE, AND THE DEVELOPMENT OF A PROPOSAL TO CREATE A PROFESSIONALS HEALTH PROGRAM ON BEHALF OF THE HOSPITAL. 0 DAVE MOULTHROP FORMER OFFICER 207526 DAVE MOULTHROP, A FORMER OFFICER, PROVIDES CONSULTING SERVICES TO ROGERS MEMORIAL HOSPITAL. 0 TOWN BANK ROGER JENSEN, BOARD MEMBER 125000 TOWN BANK PROVIDES FINANCIAL SERVICES TO ROGERS MEMORIAL HOSPITAL. 0 J PAHLAVAN SPOUSE OF KAMBIZ PAHLAVAN 143744 J. PHALAVAN IS A PROGRAM MANAGER EMPLOYED BY ROGERS MEMORIAL HOSPITAL. 0 C HENRICKS SPOUSE OF WILLIAM HENRICKS 63755 C HENRICKS IS A PROGRAM MANAGER EMPLOYED BY ROGERS MEMORIAL HOSPITAL. 0 Form 990, Part VI, Section A, line 2 BOARD MEMBER ANDRITSCH IS AN EMPLOYEE OF VJS CONSTRUCTION WHICH BOARD MEMBER JORGENSEN IS AN OWNER OF. Form 990, Part VI, Section A, line 6 ROGERS BEHAVIORAL HEALTH SYSTEM IS THE SOLE CORPORATE MEMBER. Form 990, Part VI, Section A, line 7a PER THE BY-LAWS, ADDITIONAL MEMBERS OF THE BOARD OF DIRECTORS SHALL BE DETERMINED BY THE SOLE CORPORATE MEMBER FROM TIME TO TIME. Form 990, Part VI, Section A, line 7b THE FOLLOWING ACTIONS MUST BE APPROVED BY THE SOLE MEMBER OF THE ORGANIZATION, ROGERS BEHAVIORAL HEALTH SYSTEM: 1) SELLING OR DISPOSING OF A MATERIAL PART OF THE CORPORATION'S ASSETS, 2) LENDING OR BORROWING MONEY OTHER THAN PURSUANT TO AN APPROVED LINE OF CREDIT, 3) GRANTING A MORTGAGE OR SUBJECTING TO ANOTHER SECURITY INTEREST ANY MATERIAL PORTION OF THE CORPORATION'S ASSETS, 4) ENTERING INTO CONTRACTS OR AGREEMENTS WITH PERSONS WHICH, INDIVIDUALLY, OR AS TO THE SAME PARTY, IN AGGREGATE CALL FOR THE PAYMENT BY THE CORPORATION OF AMOUNTS WHICH ARE GREATER THAN SUCH AMOUNTS WHICH ARE APPROVED BY RESOLUTION OF THE MEMBER FROM TIME TO TIME. THE MEMBER MAY ESTABLISH LIMITATIONS OF DIFFERING SIZES FOR DIFFERENT TYPES OF EXPENDITURES AND AREAS TO WHICH THESE LIMITS ARE NOT APPLICABLE, 5) UNDERTAKING MAJOR CAPITAL IMPROVEMENTS TO OR OTHERWISE REHABILITATING THE CORPORATION'S PROPERTIES, 6) CONFESSING A JUDGEMENT AGAINST THE CORPORATION, 7) MAKING ANY CHANGES OR AMENDMENTS TO THE CORPORATION'S ARTICLES OF INCORPORATION OR BYLAWS. Form 990, Part VI, Section B, line 11 KEITH DEGNER, CFO, COMPLETES A DETAILED REVIEW OF THE 990 PRIOR TO MAKING THE 990 AVAILABLE TO THE BOARD MEMBERS. THE FORM 990 IS MADE AVAILABLE TO THE BOARD MEMBERS THROUGH THE BOARD'S WEBSITE SO THEY CAN REVIEW AND COMMENT ON IT PRIOR TO FILING. Form 990, Part VI, Section B, line 12c Roger's Memorial Hospital's Directors and officers shall, should a conflict arise at any time, promptly disclose such conflict in writing to the chairperson of the board of directors; and in matters where a member has a conflict that requires a vote, abstain. Annually, the conflict of interest form will be submitted to the chairman of the board. In addition, each administrative staff member, medical staff officer, medical/administrative agent, and employee involved in purchasing supplies and equipment for the hospital shall have a conflict of interest statement on file in the president's office and those statements shall be updated annually and whenever there is a need for additions or deletions. Form 990, Part VI, Section B, line 15 THE CEO'S COMPENSATION IS DETERMINED BY INDUSTRY ANALYSIS AND IS SUPPORTED BY AN ANALYSIS BY AN EXTERNAL CONSULTANT. APPROVAL OF THE RESULTS IS BY THOSE BOARD MEMBERS WITHOUT CONFLICT OF INTEREST AND THE APPROVAL IS DOCUMENTED. OTHER KEY OFFICERS' COMPENSATION IS DETERMINED BY INDUSTRY ANALYSIS SIMILAR TO THE PROCESS USED TO DETERMINE THE CEO'S COMPENSATION. Form 990, Part VI, Section C, line 19 ROGER'S MEMORIAL HOSPITAL DOES NOT MAKE ITS GOVERNING DOCUMENTS OR CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC. THE FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC AS THEY ARE ATTACHED TO THE FILED IRS FORM 990 AND SUBSEQUENTLY PUBLISHED ONLINE BY THE IRS. Form 990, Part XI, line 9: CHANGE IN INTEREST IN NET ASSETS OF ROGERS MEMORIAL HOSPITAL FOUNDATION, IN 1,119,522. NET ASSETS RELEASED FROM RESTRICTION -123,461. Form 990, Part XII, Line 2c: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. Partners in Behavioral Health 34700 Valley Road Oconomowoc WI 53066 391832142 To assist its subsidiaries in providing behavioral health services WI 228368 74226 Rogers Memorial Hospital ROGERS BEHAVIORAL HEALTH SYSTEM INC 34700 VALLEY ROAD OCONOMOWOC WI 53066 263902724 TO ASSIST ITS SUBSIDIARIES IN PROVIDING BEHAVIORAL HEALTH SERVICES WI 501(c)(3) Line 11b, II N/A 0 ROGERS MEMORIAL HOSPITAL FOUNDATION INC 34700 VALLEY ROAD OCONOMOWOC WI 53066 391363507 TO SUPPORT ALL ENTITIES OF ROGER'S BEHAVIORAL HEALTH SYSTEM, INC. WI 501(c)(3) Line 9 ROGERS BEHAVIORAL HEALTH SYSTEM INC 1 ROGERS INHEALTH INC 34700 VALLEY ROAD OCONOMOWOC WI 53066 463960059 IMPLEMENTS AND PROMOTES ACCESSIBLE EDUCATION AND ADVOCACY RESOURCES WI 501(c)(3) Line 9 ROGERS BEHAVIORAL HEALTH SYSTEM INC 1 1 1 1 0 0 0 0 0 0 0 1 1 1 1 1 0 1 0 1 Rogers Memorial Hospital Foundation B 1482098 FMV of Grants Paid and Serv Perf Rogers Memorial Hospital Foundation C 155307 FMV of Grants Paid Rogers InHealth Inc B 496267 FMV of Services Performed Rogers Behavioral Health System Inc M 1295000 FMV of Services Performed