2014-05-11T17:52:24-05:00 2013-06-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2012-07-01 561479712 CAROMONT MEDICAL GROUP INC CARO 7048342000 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 280531747 DAVID O'CONNOR 7048342000 2014-05-11 1 AMY BIBBY P00445891 8282542254 2012 2015-11-30 17:44:51Z DAVID O'CONNOR 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 280531747 112903494 0 X WWW.CAROMONT.ORG X 1985 NC TO PROVIDE EXCEPTIONAL HEALTH CARE TO THE COMMUNITIES WE SERVE. 3 3 829 0 0 0 0 25293 88855499 87106169 4467184 3323993 1325719 2333958 94648402 92789413 16000 4800 0 0 79865266 79985121 0 0 0 27830854 25464613 107712120 105454534 -13063718 -12665121 83328621 72766218 9071008 8224707 74257613 64541511 X TO PROVIDE EXCEPTIONAL HEALTH CARE TO THE COMMUNITIES WE SERVE. 0 0 99181657 4800 87106169 SEE SCHEDULE O.CAROMONT MEDICAL GROUP OWNS AND OPERATES A NETWORK OF OVER 40 PRIMARY CARE AND SPECIALTY PHYSICIAN PRACTICES AND THREE URGENT CARE CENTERS. IT EMPLOYS OVER 110 PHYSICIANS AND 55 PHYSICIAN EXTENDERS IN TWENTY-THREE DIFFERENT SPECIALTIES. CAROMONT MEDICAL GROUP IS COMMITTED TO PROVIDING HIGH QUALITY CARE TO ITS PATIENTS. 100% OF ITS PRIMARY CARE PRACTICES HAVE BEEN CERTIFIED AS A LEVEL 3 PATIENT-CENTERED MEDICAL HOME. THIS HIGHEST LEVEL OF CERTIFICATION AVAILABLE TO PRIMARY CARE PRACTICES BY THE NATIONAL CENTER FOR QUALITY ASSURANCE (NCQA) RECOGNIZES PRACTICES THAT EMPHASIZE CARE COORDINATION AND COMMUNICATION TO IMPROVE QUALITY OUTCOMES FOR THEIR PATIENTS. IN ADDITION, 75% OF SPECIALTY PHYSICIAN PRACTICES HAVE BEEN CERTIFIED AS A LEVEL 3 PHYSICIAN PRACTICE CONNECTIONS. THIS HIGHEST LEVEL OF CERTIFICATION AVAILABLE TO SPECIALTY PRACTICES BY THE NCQA RECOGNIZES PRACTICES THAT USE SYSTEMATIC PROCESSES AND INFORMATION TECHNOLOGY TO IMPROVE THE QUALITY OF PATIENT CARE. 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. 99181657 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 1 193 0 1 829 1 0 0 0 0 0 0 0 0 0 0 X 3 3 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 DR ROBERT CROUCH 1.00 1.00 X X 0 0 0 SHEILA REILLY PHD 1.00 1.00 X X 0 0 0 W BARRY SMITH 1.00 1.00 X 0 0 0 MS SUSIE BROWN 1.00 1.00 X 0 0 0 RANDALL L KELLEY 1.00 49.00 X 0 832695 166291 DOUG LUCKETT 1.00 49.00 X 0 508051 85174 DAVID O'CONNOR 1.00 49.00 X 0 483333 93652 MARIA LONG 1.00 49.00 X 0 383962 47836 DR AJAYPARTAP S BAJWA 40.00 X 658459 0 30271 DR OMER L SHEDD 40.00 X 689787 0 41387 DR DUSTIN P LETTS 40.00 X 710654 0 24093 DR JAMES P GREELISH 40.00 X 883217 0 42670 DR LOUIS DALESSANDRO 40.00 X 905583 0 27107 3847700 2208041 558481 163 0 1 0 ATHENA HEALTH PO BOX 415615 BOSTON MA 02241 PHYSICIAN MANAGEMENT SYSTEM 4642038 MEDICUS CONSULTING SERVICES LLC 7 INDUSTRIAL WAY UNIT 5 SALEM NH 03079 LOCUM TENENS FOR INPATIENT HOSPITAL PROG 2082362 STAFF CARE INC PO BOX 281923 ATLANTA GA 30384 LOCUM TENENS FOR INPATIENT HOSPITAL PROG 428343 NEXTGEN HEALTHCARE PO BOX 809390 CHICAGO IL 60680 SYSTEM COSTS, SOFTWARE LICENSES, AND MAI 425884 JAMES ANTEZANNA 13727 GRAND PALISADES PARKWAY CHARLOTTE NC 28260 TEMPORARY CONTRACTED COVERAGE FOR VASCUL 271200 13 25293 25293 PATIENT SERVICE REVENUE 621400 87106169 87106169 87106169 1435414 1435414 22002660 19673043 441038 2329617 -441038 1888579 1888579 MEANINGFUL USE 900099 1371032 1371032 MISCELLANEOUS 621400 924069 924069 MANAGEMENT FEE INCOME 561000 38857 38857 2333958 92789413 87106169 0 5657951 4800 4800 68944484 65255429 3689055 1949178 1831862 117316 5610730 5023101 587629 3480729 3179830 300899 669 500 169 99475 99475 550807 73356 477451 127640 111823 15817 1102240 1000480 101760 6419610 6110755 308855 86526 56831 29695 1750599 1223875 526724 1457611 1439728 17883 MEDICAL SUPPLIES 9929947 9929798 149 BAD DEBT 3939489 3939489 105454534 99181657 6272877 0 367764 197435 7199853 5265023 200000 200000 788170 954735 316003 136497 15029870 5905558 6533048 9124312 63847998 52679518 3523153 3523153 552632 685545 83328621 72766218 8825721 8224707 116584 0 128703 0 9071008 8224707 X 74257613 64541511 74257613 64541511 83328621 72766218 -12665121 2949019 0 X X 0 1 X 1 0 X 25293 25293 67183894 75579994 74250177 88855499 87106169 392975733 951649 1032851 655676 1161305 2333958 6135439 68135543 76612845 74905853 90016804 89465420 399136465 0 0 0 399136465 951649 1471631 1701412 1457535 1435414 7017641 951649 1471631 1701412 1457535 1435414 7017641 69087192 78084476 76607265 91474339 90900834 406154106 0.98270 0.97470 0.01730 0.02530 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2296965 2296965 4475308 1295918 3179390 46641 1262 45379 8210956 4608378 3602578 9124312 X 91660611 2949019 -4038964 -1089945 92750556 38857 38857 92789413 101376713 -38857 -38857 101415570 4038964 4038964 105454534 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: 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, 2013 AND 2012, RESPECTIVELY. FISCAL YEARS ENDING ON OR AFTER JUNE 30, 2010 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT -3,939,489. INVESTMENT MANAGEMENT FEES NETTED WITH REVENUE -99,475. PART XI, LINE 4B - OTHER ADJUSTMENTS: MANAGEMENT FEE INCOME NET WITH FEES EXPENSE 38,857. PART XII, LINE 2D - OTHER ADJUSTMENTS: MANAGEMENT FEE INCOME NET WITH FEES EXPENSE -38,857. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT 3,939,489. INVESTMENT MANAGEMENT FEES 99,475. X X X X X 0 1 0 0 0 1 1 0 0 RANDALL L KELLEY 0 577693 0 232988 0 22014 0 156204 0 10087 0 998986 0 0 DOUG LUCKETT 0 372857 0 127707 0 7487 0 74601 0 10573 0 593225 0 0 DAVID O'CONNOR 0 351082 0 124821 0 7430 0 79460 0 14192 0 576985 0 0 MARIA LONG 0 280995 0 102230 0 737 0 45890 0 1946 0 431798 0 0 DR AJAYPARTAP S BAJWA 658459 0 0 0 0 0 27000 0 3271 0 688730 0 0 0 DR OMER L SHEDD 511193 0 178594 0 0 0 26850 0 14537 0 731174 0 0 0 DR DUSTIN P LETTS 513157 0 197497 0 0 0 9850 0 14243 0 734747 0 0 0 DR JAMES P GREELISH 792217 0 77000 0 14000 0 26850 0 15820 0 925887 0 0 0 DR LOUIS DALESSANDRO 205972 0 698832 0 779 0 19967 0 7140 0 932690 0 0 0 PART I, LINE 4B THE FOLLOWING INDIVIDUALS RECEIVED DEFERRED COMPENSATION ALLOCATIONS BY RELATED ORGANIZATION GASTON MEMORIAL HOSPITAL FROM A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP): DAVID O'CONNOR - $ 69,460 MARIA LONG - 34,427 DOUG LUCKETT - 72,101 RANDALL L. KELLEY - 152,984 DR. AJAYPARTAP S. BAJWA - 17,000 DR. OMER L. SHEDD - 17,000 DR. JAMES P. GREENLISH - 17,000 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 AND FINANCIAL PERFORMANCE OF THE CONSOLIDATED SYSTEM. MANAGER INCENTIVE PLAN BASED ON CONSOLIDATED CORPORATE AND INDIVIDUAL PERFORMANCE GOALS. JAMES P GREELISH MD PHYSICIAN EMPLOYED BY THE ORGANIZATION HOUSING LOAN X 200000 200000 0 1 1 200000 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 APPLICABLE EMPLOYEE AND DIRECTOR SHALL FULLY AND TRUTHFULLY COMPLETE A QUESTIONNAIRE CONCERNING POTENTIAL AND ACTUAL CONFLICTS OF INTEREST ANNUALLY. SUCH QUESTIONNAIRE SHALL IDENTIFY THE EMPLOYEE'S OBLIGATION TO IMMEDIATELY MAKE THE CORPORATE RESPONSIBILITY OFFICER AWARE IN WRITING OF ANY POTENTIAL OR ACTUAL CONFLICTS OF INTEREST AS THEY MAY ARISE AND CONTAIN SAID EMPLOYEE'S AGREEMENT TO ABIDE BY ALL TERMS AND CONDITIONS OF THIS POLICY AS A CONDITION OF RETAINING THEIR POSITION. SUCH QUESTIONNAIRES SHALL BE REVIEWED ANNUALLY BY THE CHIEF LEGAL OFFICER AND THE CORPORATE RESPONSIBILITY OFFICER. FORM 990, PART VI, SECTION B, LINE 15 THE CEO, CFO AND CHIEF LEGAL OFFICER ARE COMPENSATED FOR THEIR SERVICES BY GASTON MEMORIAL HOSPITAL, 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. PURSUANT TO THE COMMITTEE CHARTER FOR THE COMPENSATION COMMITTEE OF THE BOARD, THE BOARD OF DIRECTORS APPROVES THE EXECUTIVE COMPENSATION PHILOSOPHY, WHICH ESTABLISHES THE PARAMETERS FOR ALL EXECUTIVE COMPENSATION DECISIONS. THE BOARD OF DIRECTORS DELEGATES ALL COMPENSATION DECISIONS FOR ALL EXECUTIVES TO THE COMPENSATION COMMITTEE, PROVIDED SUCH DECISIONS ARE CONSISTENT WITH THE COMPENSATION PHILOSOPHY. BOARD APPROVAL MUST BE OBTAINED WHEN COMPENSATION DECISIONS DEVIATE FROM THE COMPENSATION PHILOSOPHY. 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 LEAVES THE MEETING AND 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 DIRECTORS AND 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. RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT: PART XII, LINE 2C THIS PROCESS HAS NOT CHANGED FROM PRIOR YEARS. CAROMONT SPECIALITY GROUP LLC 2240 REMOUNT RD GASTONIA NC 28054 522451748 MEDICAL SERVICES NC 0 0 CAROMONT MEDICAL GROUP INC CAROMONT SOUTH POINT LLC 2240 REMOUNT RD GASTONIA NC 28054 205453221 MEDICAL SERVICES NC 13400907 833353 CAROMONT MEDICAL GROUP INC CMG - GASTON WOMENS HEALTHCARE LLC 2240 REMOUNT RD GASTONIA NC 28054 205894683 MEDICAL SERVICES NC 4976647 318763 CAROMONT MEDICAL GROUP INC CMG - FAMILY MEDICINE OF CLEVELAND COUNTY LLC 2240 REMOUNT RD GASTONIA NC 28054 205925671 MEDICAL SERVICES NC 0 0 CAROMONT MEDICAL GROUP INC ASHLEY WOMENS CMG LLC 2240 REMOUNT RD GASTONIA NC 28054 264369018 MEDICAL SERVICES NC 11561396 977559 CAROMONT MEDICAL GROUP INC CS CMG LLC 2240 REMOUNT RD GASTONIA NC 28054 272146660 MEDICAL SERVICES NC 0 0 CAROMONT MEDICAL GROUP INC GS CMG LLC 2240 REMOUNT RD GASTONIA NC 28054 272146801 MEDICAL SERVICES NC 0 0 CAROMONT MEDICAL GROUP INC CAROMONT HEALTH INC 2525 COURT DRIVE GASTONIA NC 28054 581636959 MEDICAL SERVICES NC 501(C)(3) LINE 11B, II N/A 0 CAROMONT HEALTH SERVICES INC 2526 COURT DRIVE GASTONIA NC 28054 561455630 OUTPATIENT SERVICES NC 501(C)(3) LINE 3 CAROMONT HEALTH INC 0 GASTON MEMORIAL HOSPITAL FOUNDATION INC 2527 COURT DRIVE GASTONIA NC 28054 561479699 FOUNDATION NC 501(C)(3) LINE 9 CAROMONT HEALTH INC 0 HOSPICE OF GASTON COUNTY INC 2529 COURT DRIVE GASTONIA NC 28054 581341530 HOSPICE CARE NC 501(C)(3) LINE 7 CAROMONT HEALTH INC 0 GASTON MEMORIAL HOSPITAL INC 2530 COURT DRIVE GASTONIA NC 28054 560619359 HOSPITAL NC 501(C)(3) LINE 3 CAROMONT HEALTH INC 0 GASTON EMERGENCY PHYSICIANS INC 2531 COURT DRIVE GASTONIA NC 28054 562209423 SUPPORTING ORGANIZATION NC 501(C)(3) LINE 11A, I CAROMONT HEALTH INC 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1