2014-05-13T11:03:54-05:00 2013-06-30 BKD LLP 910 E St Louis Street Suite 200 Springfield MO 65806 990 2012-07-01 232449454 Susquehanna Physician Services SUSQ 5703207900 1201 Grampian Boulevard Williamsport PA 17701 Charles J Santangelo 5703213171 2014-05-13 1 Brian D Todd P00422601 4178658701 2012 2015-11-30 17:44:51Z Susquehanna Health Medical Group Steven P Johnson 777 Rural Avenue Williamsport PA 17701 73830615 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. 24 14 609 43 0 0 13207042 16375486 62288386 57437589 3097 12673 0 0 75498525 73825748 181305 0 0 0 58675258 58935460 0 0 0 17976175 16239361 76832738 75174821 -1334213 -1349073 15960966 14521972 10362546 10272625 5598420 4249347 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 a high quality patient centered integrated delivery system. Our values are to demonstrate extraordinary CARE for those who receive our services; share ownership with those who provide our services; and be servant leaders whose behaviors are rooted in quality service, dedicated partnership, responsible stewardship, and commitment to our regional community. 0 0 69197715 56301158 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, 2013there were approximately 615,750 patient visits for SPS. 1007320 1136431 Susquehanna Physician Services operates an outpatient MRI center that services patients from Lycoming and surrounding communities. During the fiscal year ended 6/30/13 the center did 1,882 scans. 70205035 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 609 1 0 0 0 0 0 0 0 0 0 0 X 24 14 0 0 1 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 1.00 1.00 X X 0 0 0 Ann S Pepperman Esquire 1.00 1.00 X X 0 0 0 Davie Jane Gilmour Ph D 1.00 1.00 X X 0 0 0 Sister Teresa Ann Jacobs 1.00 2.00 X 0 0 0 John M Burks MD 40.00 1.00 X 423058 0 29130 Leonard R Collins MD 40.00 3.00 X 260644 0 24456 Ronald E DiSimone MD 40.00 1.00 X 971504 0 30107 James Douthat Ed D 1.00 X 0 0 0 Lynda Livingston 1.00 2.00 X 0 0 0 Timothy M Gage 1.00 1.00 X 0 0 0 Daniel J Glunk MD 20.00 21.00 X 0 201627 6578 Sister Joan Daniel Healy 1.00 X 0 0 0 Steven P Johnson 1.00 43.00 X X 0 962143 32509 Daniel A Klingerman 1.00 1.00 X 0 0 0 Philip H Johnson 1.00 1.00 X 0 0 0 Dr Stephen Weber 40.00 X 300370 0 25535 James E Mothersbaugh 1.00 1.00 X X 0 0 0 Alexander R Nesbitt MD 40.00 3.00 X 186910 0 29074 Kevin W Kist Jr DO 40.00 4.00 X 351380 0 33016 Robert DeCamp 1.00 3.00 X 0 0 0 Walter Laibinis 1.00 43.00 X 0 235052 12795 Dr J Dennis Murray 1.00 3.00 X 0 0 0 Glenn Poirier 1.00 3.00 X 0 0 0 Charles J Santangelo 1.00 40.00 X 0 358326 29369 Susan A Branton 40.00 X 417490 0 28702 Rene Rigal MD 40.00 X 346471 0 37898 Dr James Campbell 1.00 X 0 0 0 Melissa Welch 1.00 3.00 X 0 0 0 Paul Rooney 1.00 1.00 X 0 0 0 George Manchester MD 1.00 40.00 X 0 354682 21682 Richard Schluter 1.00 X 0 0 0 James J Turri 40.00 X 227641 0 10510 Jan E Fisher 0.00 40.00 X 0 333591 22798 Ronald J Butler 0.00 40.00 X 0 367109 19857 William C McCauley MD 40.00 X 403160 0 31423 Neil G Armstrong 0.00 40.00 X 0 293762 27670 Sabrina Dowd MD 40.00 X 703566 0 29939 Karla Anderson MD 40.00 X 538387 0 22570 Michael V Hoffman MD 40.00 X 626047 0 28672 Dr Edward Wyshock 40.00 X 1324069 0 28358 David C Schaefer 40.00 X 681262 0 9019 7761959 3106292 571667 107 0 1 0 Comphealth Medical Staffing PO Box 972651 Dallas TX 75397 Temporary Employment 595814 Susquehanna Imaging Associates 700 High Street Williamsport PA 17701 MRI Scans 231500 Linde Healthcare Staffing PO Box 915241 Dallas TX 75391 Temporary Employment 195407 LocumTenenscom PO Box 405547 Atlanta GA 30384 Temporary Employment 179973 The Crimson Intiative PO Box 79461 Baltimore MD 21279 Decision Support 135400 13 16375486 16375486 Net Patient Services 621110 45757365 45757365 Inter-Entity SSA 621110 7185702 7185702 MRI Scans 621400 1136431 1136431 Capitation Payments 621110 647149 647149 Inter-Entity Revenue 621110 337430 337430 2373512 2373512 57437589 17540 4867 12673 12673 12673 73825748 57437589 0 12673 3118751 2715591 403160 47284699 45054834 2229865 1758114 1634109 124005 4199525 3966759 232766 2574371 2415521 158850 911410 911410 3420 3420 1013084 1013084 86004 86004 314036 294118 19918 700776 427285 273491 2748929 2380354 368575 65367 51445 13922 351047 317193 33854 235637 235637 1020844 927570 93274 2030227 2028824 1403 Medical Supplies 3059776 3059776 Provision For Bad Debt 2366583 2366583 Books Subscriptions Due 276951 237980 38971 Minor Equipment 108886 96941 11945 946384 895427 50957 75174821 70205035 4969786 0 1146260 828560 6217690 5780094 26121 8969 876919 884044 700000 330853 681036 521093 18073036 11925534 6292083 6147502 20857 20857 15960966 14521972 9562546 9472625 800000 800000 10362546 10272625 X 5598420 4249347 5598420 4249347 15960966 14521972 -1349073 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 41973 41973 373321 373046 275 1945985 1208826 737159 11133945 9417099 1716846 4577812 926563 3651249 6147502 Third Party Payors 800000 800000 55083679 -2366583 -2366583 57450262 16375486 16375486 73825748 72808238 0 72808238 2366583 2366583 75174821 Part XI, Line 2d - Other Adjustments: Provision for doubtful accounts Part XI, Line 4b - Other Adjustments: Transfers from affliates Part XII, Line 4b - Other Adjustments: Provision for doubtful accounts 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 -$2,366,583 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 $7,355,815 Divine Providence Hospital $6,375,321 and Muncy Valley Hospital $2,644,350. Part XIII Line 4b - Provision for doubtful accounts of $2,366,583 are not included in expenses on the audited financial statements. Central America Program Services Captive insurance company 2030227 0 0 0 0 0 0 2030227 0 2030227 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 John M Burks MD 396285 0 0 0 26773 0 9500 0 19630 0 452188 0 0 0 Leonard R Collins MD 244600 0 0 0 16044 0 9500 0 14956 0 285100 0 0 0 Ronald E DiSimone MD 845483 0 114684 0 11337 0 9500 0 20607 0 1001611 0 0 0 Daniel J Glunk MD 0 183217 0 16693 0 1717 0 2899 0 3679 0 208205 0 0 Steven P Johnson 0 511232 0 139282 0 311629 0 13250 0 19259 0 994652 0 0 Dr Stephen Weber 277854 0 18660 0 3856 0 12000 0 13535 0 325905 0 0 0 Alexander R Nesbitt MD 174228 0 0 0 12682 0 10532 0 18542 0 215984 0 0 0 Kevin W Kist Jr DO 350414 0 0 0 966 0 9500 0 23516 0 384396 0 0 0 Walter Laibinis 0 178483 0 56569 0 0 0 5641 0 7154 0 247847 0 0 Charles J Santangelo 0 331316 0 19112 0 7898 0 9500 0 19869 0 387695 0 0 Susan A Branton 344682 0 68469 0 4339 0 9500 0 19202 0 446192 0 0 0 Rene Rigal MD 338594 0 0 0 7877 0 17625 0 20273 0 384369 0 0 0 George Manchester MD 0 327809 0 21083 0 5790 0 0 0 21682 0 376364 0 0 James J Turri 207252 0 15644 0 4745 0 0 0 10510 0 238151 0 0 0 Jan E Fisher 0 283326 0 49437 0 828 0 10346 0 12452 0 356389 0 0 Ronald J Butler 0 293922 0 72441 0 746 0 13971 0 5886 0 386966 0 0 William C McCauley MD 376235 0 23425 0 3500 0 9500 0 21923 0 434583 0 0 0 Neil G Armstrong 0 276505 0 14286 0 2971 0 15750 0 11920 0 321432 0 0 Sabrina Dowd MD 616287 0 81381 0 5898 0 9500 0 20439 0 733505 0 0 0 Karla Anderson MD 409865 0 123777 0 4745 0 9500 0 13070 0 560957 0 0 0 Michael V Hoffman MD 562020 0 58528 0 5499 0 9500 0 19172 0 654719 0 0 0 Dr Edward Wyshock 403995 0 867866 0 52208 0 9500 0 18858 0 1352427 0 0 0 David C Schaefer 675513 0 0 0 5749 0 0 0 9019 0 690281 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. Supplemental Information Part III Part I, Line 3: Susquehanna Health System (SHS), EIN # 23-2751183, a related organization, uses the following resources to establish the compensation of the top management officials; compensation committee, independent compensation consultant, written employment contract, compensation survey or study and approval by the board. Dr David Schaefer Employed Physician Start Up Loan X 50000 8969 0 0 1 8969 Form 990, Part VI, Section A, line 4 On March 3, 2013 the Board of Directors of Susquehanna Physician Services were relieved of their responsibilities and replaced with the Susquehanna Health System Board of Directors. 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. 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. NUMBER REPORTED IN BOX 3 OF FORM 1096 Form 990, Part V, Line 1A All 1099's are issued by Susquehanna Health System, EIN # 23-2751183. All expenses are then allocated back to all related entities. NUMBER OF EMPLOYEES REPORTED ON FORM W-3 FORM 990, PART V, LINES 2A & 2B Susquehanna Health System (SHS), EIN # 23-2751183 utilizes a common paymaster which includes the following entities: Divine Providence Hospital of the Sisters of Christian Charity, EIN # 24-0799343 Muncy Valley Hospital, EIN # 24-0806023 The Williamsport Hospital, EIN # 24-0795508 Susquehanna Health Foundation, EIN # 23-2743470 Susquehanna Physician Services, EIN # 23-2449454 Williamsport Area Ambulance Service Cooperative, EIN # 23-2416166 Providence Cancer Treatment Services, EIN # 23-2925354 The total number of employees reported on Form W-3 would be 3,482 for Susquehanna Health System. Included in that total were 609 employees whose expenses were reported by Susquehanna Physician Services. 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 11a, I 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