2014-11-17T16:15:07-06:00 2013-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2013-01-01 470408242 CHEYENNE COUNTY HOSPITAL ASSOCIATION INC CHEY 3082545825 645 OSAGE STREET SIDNEY NE 69162 JASON PETIK CEO 3082545825 2014-11-17 1 BARBARA J FAJEN P00400874 4023302660 2013 2015-11-30 17:44:51Z SIDNEY REGIONAL MEDICAL CENTER KELLY UTLEY 645 OSAGE STREET SIDNEY NE 69162 44030894 0 X WWW.SIDNEYRMC.COM X 1951 NE FOCUS ON THE NEEDS OF THOSE SERVED THROUGH THE DELIVERY OF HIGH QUALITY AND COMPASSIONATE CARE. 13 11 435 100 0 0 93508 92884 37787380 43755550 76507 72465 157073 109995 38114468 44030894 0 0 0 0 19286514 22738911 0 0 0 15272166 16627707 34558680 39366618 3555788 4664276 34308543 38093883 5519538 4640602 28789005 33453281 X OUR MISSION IS TO FOCUS ON THE NEEDS OF THOSE WE SERVE THROUGH THE DELIVERY OF HIGH QUALITY AND COMPASSIONATE CARE. 0 0 2974228 6688481 THE HOSPITAL NURSING DEPARTMENT PROVIDED 2,982 PATIENTS DAYS OF CARE IN 2013, DELIVERING 39 NEWBORNS FOR THE ELEVEN COUNTY AREA THAT SIDNEY REGIONAL MEDICAL CENTER (SRMC) SERVES. SRMC HAD 3,305 PATIENTS SEEK CARE IN THE EMERGENCY DEPARTMENT DURING 2013. 2049052 3871015 THE EXTENDED CARE UNIT PROVIDED CARE FOR AN AVERAGE OF 52 PATIENTS DAILY DURING 2013. SRMC PROVIDED 18,851 PATIENT DAYS OF CARE FOR RESIDENTS IN THE CHEYENNE, DEUEL, KIMBALL AND SURROUNDING AREAS. 1884467 4858126 SRMC PHARMACY DEPARTMENT HAS BEEN ACTIVELY INVOLVED WITH THE QUALITY OF CARE PROVIDED TO ALL PATIENTS BOTH IN THE ACUTE AND OUT PATIENT SETTINGS. THE PHARMACY DEPARTMENT HAS HELPED PROVIDE CARE FOR THOSE INDIVIDUALS WITH THE TREATMENT FOR RADIATION OR CHEMOTHERAPY. 31221801 28337928 OTHER MISCELLANOUES PATIENT SERVICES. 31221801 28337928 38129548 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 72 0 1 435 1 0 0 0 0 0 0 0 0 0 0 X 13 11 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X KELLY UTLEY 3082545825 645 OSAGE STREET SIDNEY NE 69162 X WILLIAM PILE CHAIRMAN 1.00 0.00 X X 0 0 0 TIM MILLER VICE CHAIRMAN 1.00 0.00 X X 0 0 0 TOM MILLMAN SECRETARY 1.00 0.00 X X 0 0 0 JEFF ELLWANGER TREASURER 1.00 0.00 X X 0 0 0 STAN BELIEU MEMBER 1.00 1.00 X 0 0 0 JIM JONES MEMBER 1.00 0.00 X 0 0 0 MICHAEL MATTHEWS MD MEMBER - PHYSICIAN AT LARGE 40.00 0.00 X 372090 0 0 KATHY NARJES MEMBER 1.00 0.00 X 0 0 0 ROB ROBINSON MEMBER 1.00 0.00 X 0 0 0 DWIGHT SMITH MEMBER 1.00 0.00 X 0 0 0 JAMES THAYER MD MEMBER - CHIEF OF STAFF SURGEON 40.00 0.00 X 342135 0 36467 JULIE WAMSLEY MEMBER 1.00 0.00 X 0 0 0 LAURIE WIDOWSON MEMBER 1.00 0.00 X 0 0 0 JASON PETIK CEO 39.00 1.00 X 0 0 0 KELLY UTLEY CFO 39.00 1.00 X 136952 0 24219 MANDY SHAW DOCTOR 40.00 0.00 X 409711 0 17500 KENNETH MARTIN CRNA 40.00 0.00 X 219941 0 38781 DANA HLAVINKA CRNA 40.00 0.00 X 219580 0 34486 CALVIN CUTRIGHT DOCTOR 40.00 0.00 X 233824 0 18967 CLINTON DORWART DOCTOR 40.00 0.00 X 213641 0 36022 2147874 0 206442 28 0 1 1 RURAL PARTNERS IN MEDICINE LLC PO BOX 772519 STEAMBOAT SPRINGS CO 80477 PHYSICIAN SERVICES 1646205 BYTES COMPUTER & NETWORK SOLUTIONS INC 1712 AVENUE B SCOTTSBLUFF NE 69361 IT SERVICES 306223 POUDRE VALLEY HEALTH CARE INC PO BOX 2103 FORT COLLINS CO 80522 MANAGEMENT SERVICES 233991 SHARED MEDICAL SERVICES INC PO BOX 330 COTTAGE GROVE WI 53527 MRI LEASE 196900 HEALTH CAROUSEL LLC PO BOX 44743 MIDDLETOWN OH 45044 HOME HEALTH CONTRACT SERVICES 159884 9 27178 65706 92884 NET PATIENT SERVICE REVENUE 624100 25298223 25298223 MEDICARE/MEDICAID 624100 16975671 16975671 340B REVENUE 624100 945835 945835 HOME CARE 621610 236420 236420 HIT INCENTIVE PAYMENT 624100 69000 69000 230401 230401 43755550 72465 72465 CAFETERIA 624100 97819 97819 PATRONAGE DIVIDEND 624100 12176 12176 109995 44030894 43755550 0 182460 X 161171 161171 811858 750692 61166 16573940 16304717 269223 475033 467763 7270 3517765 3440920 76845 1199144 1155263 43881 233991 233991 46174 46174 83765 83765 4155374 4097932 57442 143066 143066 1463174 1451030 12144 518348 518348 934908 934908 147835 135950 11885 46805 46805 1244265 1244265 539567 539567 MEDICAL SUPPLIES 4735289 4735289 BAD DEBTS 1881022 1881022 TAXES & LICENSES 91545 67617 23928 DUES AND SUBSCRIPTIONS 75534 28062 47472 287045 233137 53908 39366618 38129548 1237070 0 4547176 4699797 9240879 12808661 6549084 6123177 895473 968973 205422 520330 27246702 14740076 11631437 12506626 81017 84292 1158055 382027 34308543 38093883 3105212 3101089 1926291 0 233054 440515 254981 1098998 5519538 4640602 X 28789005 33438102 0 15179 28789005 33453281 34308543 38093883 4664276 0 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 5051 5051 0 PART II-B, LINE 1: A PORTION OF THE DUES PAID TO THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE NEBRASKA HOSPITAL ASSOCIATION (NHA) ARE USED BY THOSE ORGANIZATIONS FOR LOBBYING ACTIVITIES. 92500 526741 619241 15144253 8011697 7132556 21420 5101 16319 9322274 6388484 2933790 2139514 334794 1804720 12506626 DEFERRED COMPENSATION PLAN LIABILITY 379234 ESTIMATED THIRD PARTY SETTLEMENTS 719764 1098998 X PART X, LINE 2: SIDNEY REGIONAL MEDICAL CENTER AND CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION ARE EXEMPT FROM INCOME TAXES UNDER SECTION 501(A) OF THE CODE AND A SIMILAR PROVISION OF STATE LAW. HOWEVER, THEY ARE SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATED BUSINESS TAXABLE INCOME. THE SYSTEM ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE SYSTEM RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2013, THE SYSTEM HAD NO UNCERTAIN TAX POSITIONS ACCRUED. WITH FEW EXCEPTIONS, THE SYSTEM IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS BY U.S. FEDERAL, STATE, OR LOCAL AUTHORITIES FOR YEARS BEFORE 2010. 1 1 1 X 1 X 1 1 1 0 1 1 624804 624804 0.01670 2303015 2086726 216289 0.00580 2927819 2086726 841093 0.02250 228899 67349 161550 0.00430 93615 93615 0.00250 11300 11300 0.00030 333814 67349 266465 0.00710 3261633 2154075 1107558 0.02960 86 1954 7100 7100 0.00020 6 568 62720 62720 0.00170 64 8851 5500 5500 0.00010 156 11373 75320 75320 0.00200 1 1881022 705383 12016345 12205447 -189102 X 1 1 1 1 CHEYENNE COUNTY HOSPITAL ASSOCIATION 645 OSAGE STREET SIDNEY NE 69162 WWW.SIDNEYRMC.COM 150001 X X X X CHEYENNE COUNTY HOSPITAL ASSOCIATION INC 1 1 X X X X X X X X X X 11 1 1 1 X WWW.SIDNEYRMC.COM X X X X X X X X X X 1 0 1 1 100.000000000000 1 300.000000000000 1 X X X X X X 1 1 X X 1 0 X X 1 X 0 0 CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 1J: THE PANHANDLE PUBLIC HEALTH DISTRICT (PPHD) AND ALL OF THE HOSPITALS IN THE PANHANDLE OF NEBRASKA WORKED AS A NETWORK TO CREATE THE CHNA. PPHD ADMINISTERED THE SURVEY FOR THE PANHANDLE OF NEBRASKA WITH DIRECT COLLABORATION WITH ALL THE NEBRASKA PANHANDLE HOSPITALS SOLICITING OPINIONS OF THE GENERAL PUBLIC REGARDING HEALTH NEEDS. THIS INCLUDED ALL OF THE REMOTE COUNTIES IN WESTERN NEBRASKA. PRIORITY AREAS FOR COMMUNITY PARTICIPANTS INCLUDED: 1. ECONOMIC FACTORS - POVERTY AND ECONOMIC DEVELOPMENT. 2. HEALTH PROMOTION - ACCESS TO QUALITY FOOD, ACCESS TO EXERCISE EQUIPMENT/FACILITIES, FAST FOODS, HEALTHY EATING. 3. COMMUNITY CONTEXT - NO TRANSPORTATION, HEALTH CARE AVAILABILITY, RACISM, ACCEPTANCE OF ALCOHOL, JUSTICE SYSTEM, LEADERSHIP, LACK OF COMMUNITY COLLABORATION, ACTIVITIES FOR TEENS, SOCIAL NORMS.4. MOTIVATION - PARENT EDUCATION, ATTITUDES, ACCEPTANCE, INITIATIVE. THE FOLLOWING WERE IDENTIFIED AS CHALLENGES: DECREASE IN VOLUNTEERISM, POTENTIAL FOR PROGRAM CUTS IN STATE BUDGET, INCREASED GOVERNMENT INVOLVEMENT IN HEALTH CARE, SUSTAINABILITY, ECONOMIC SHIFTS, APPROPRIATE USE OF TECHNOLOGY. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 3: THE PANHANDLE PUBLIC HEALTH DISTRICT AND COMMUNITY HOSPITALS HELD PUBLIC MEETINGS FOR THE COMMUNITY FORUMS AND WORKED WITH THE HOSPITALS AND OTHER PUBLIC OFFICIALS. SURVEYS WERE SENT OUT FROM FEBRUARY 2011 TO MAY 2011. THE SURVEY WAS AVAILABLE ONLINE AND WAS SENT TO 26,000 HOUSEHOLDS WITH 564 CITIZENS RESPONDING. THE CFO OF CHEYENNE COUNTY HOSPITAL ASSOCIATION, KELLY UTLEY, PARTICIPATED IN THE PLANNING AND IN ONE OF THE FORUMS AS A REPRESENTATIVE FOR CHEYENNE COUNTY. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 4: THE FOLLOWING IS A LIST OF HOSPITALS THAT PARTICIPATED IN THE CHNA:-BOX BUTTE GENERAL HOSPITAL, ALLIANCE, NE-MORRILL COUNTY HOSPITAL, BRIDGEPORT, NE-REGIONAL WEST MEDICAL CENTER, SCOTTSBLUFF, NE-CHADRON COMMUNITY HOSPITAL, CHADRON, NE-GARDEN COUNTY HEALTH SERVICES, OSHKOSH, NE-GORDON MEMORIAL HOSPITAL, GORDON, NE-KIMBALL HEALTH SERVICES, KIMBALL, NE-SCOTTSBLUFF COUNTY HEALTH DEPARTMENT, SCOTTSBLUFF, NE-SIDNEY REGIONAL MEDICAL CENTER, SIDNEY, NE CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 6I: THROUGH THE CHNA, 4 AREAS WERE IDENTIFIED AS BEING THE FOCAL POINTS FOR COLLABORATION BETWEEN PPHD, THE PANHANDLE COUNTIES AND SRMC.1. HEALTHY LIVING 2. MENTAL & EMOTIONAL WELL BEING 3. INJURY & VIOLENCE PREVENTION 4. CANCER PREVENTION. DIABETES PREVENTION WAS ADDED AS ONE ADDITIONAL AREA TO FOCUS ON WHICH IS ADDRESSED, IN PART, BY HEALTHY EATING IN CONJUNCTION WITH HEALTHY LIVING. SRMC NURSES MAKE HOUSE CALLS TO NEW MOTHERS TO DISCUSS CARE FOR THE INFANT, HEALTHY LIVING, HEALTHY EATING, ACTIVE LIVING AND THE IMPORTANCE OF BREASTFEEDING. THESE HOUSECALLS ARE MADE TO ALL FAMILIES IN THE AREA WHO HAVE RECENTLY DELIVERED A BABY REGARDLESS OF WHETHER THE BABY WAS DELIVERED AT SRMC. DURING 2013, IN COLLABORATION WITH PPHD, SRMC IMPLEMENTED DIABETES PREVENTION EDUCATION CLASSES OFFERED TO ALL INDIVIDUALS IN THE AREA AND TO EMPLOYEES OF SRMC. THESE CLASSES ARE OFFERED AT NO COST TO THE PARTICIPANTS. SRMC HAS ALSO INCREASED ACCESS TO THE LOCAL COMMUNITY CENTER FOR EMPLOYEES TO STAY ACTIVE. SRMC HAS CO-SPONSORED, WITH THE COMMUNITY CENTER, THE "GET FIT - STAY FIT" PROGRAM WHICH HAS BEEN OFFERED TO RESIDENTS IN THE AREA. MENTAL AND EMOTIONAL WELL BEING, INJURY AND VIOLENCE PREVENTION AND CANCER PREVENTION ARE BEING TAUGHT IN THE SCHOOLS WITH THE ASSISTANCE OF THE PANHANDLE PUBLIC HEALTH DISTRICT. PREVENTION OF TOBACCO USE IS BEING TAUGHT IN THE SCHOOLS. SRMC PROVIDES SMOKING CESSATION CLASSES AND CONSULTATION FOR ALL PATIENTS AND OFFERS SUPPORT TO EMPLOYEES WHO CHOOSE TO QUIT THROUGH COUNSELING AND PHARMACEUTICALS AT NO CHARGE. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 14G: THE POLICY IS REFERENCED IN BILLING STATEMENTS AND IS VERBALLY REVIEWED THROUGH MANY AVENUES IN ADMISSIONS AND PATIENT FINANCIAL SERVICES, INCLUDING PATIENT ADVOCACY. THE POLICY IS AVAILABLE IN THE WAITING ROOMS AT THE HOSPITAL. ADDITIONALLY, FINANCIAL SERVICE REPRESENTATIVES ACTIVELY SCAN FOR ACCOUNTS WHICH COULD QUALIFY FOR CHARITY CARE AND OFFER IT WITH OTHER OPTIONS FOR PAYMENT DURING THEIR CONVERSATIONS WITH PATIENTS. A HARDCOPY OF THE POLICY IS OFFERED BY THE PATIENT ADVOCATE/FINANCIAL COUNSELOR DURING MEETINGS WITH PATIENTS. MEDICAID PATIENTS AUTOMATICALLY QUALIFY AT 100%. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 20D: ELIGIBLE PATIENTS UNDER THE FINANCIAL ASSISTANCE POLICY RECEIVE AN ADJUSTMENT ON A PERCENTAGE BASIS. THE ADJUSTMENT IS CALCULATED USING SOFTWARE WHICH TAKES INTO ACCOUNT THEIR INCOME, HOUSEHOLD STATUS, ETC. IN COMPLIANCE WITH THE POLICY. TRUE PRIVATE PAY INDIVIDUALS (UNINSURED) RECEIVE AN IMMEDIATE REDUCTION IN CHARGES EQUIVALENT TO AN AVERAGE COMMERCIAL RATE. FAP ELIGIBLE PATIENTS MAY RECEIVE A REDUCTION UP TO 100% OF CHARGES LEAVING CHARGES TO THOSE INDIVIDUALS AT ZERO. FAP ELIGIBLE PATIENTS WHO ARE ELIGIBLE FOR THE 70% OR 100% DISCOUNTS WOULD NOT BE BILLED MORE THAN THE LOWEST COMMERCIAL RATE OR MEDICAID RATE AS THESE RATES ARE HIGHER THAN 30% OF CHARGES. 2 SIDNEY REG'L MEDICAL CTR EXTENDED CARE 645 OSAGE SIDNEY NE 69162 LONG TERM CARE FACILITY SLOAN ESTATES ASSISTED LIVING 2550 CRAIG AVENUE SIDNEY NE 69162 ASSISTED LIVING PART I, LINE 3C: THE CALCULATION FOR ELIGIBILITY IS BASED ON ALL INCOME PER HOUSEHOLD WITH EXCEPTIONS MADE FOR WAGE EARNERS WHO ARE STUDENTS AND OTHER MEDICAL PAYMENTS ALREADY BEING MADE. THIS INCOME IS COMPARED TO THE NATIONAL POVERTY GUIDELINES AND A DETERMINATION OF REDUCTION IS MADE BASED ON THE ADJUSTED INCOME LEVEL. THE WRITE OFF AMOUNT MAY BE REDUCED FOR EQUITY IN ASSETS, IF ANY, ABOVE EXEMPTION THRESHHOLDS FOR HOMES AND VEHICLES. THERE IS NO EXEMPTION FOR INVESTMENTS OR OTHER ASSETS HELD. PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT IS PREPARED BY THE STAFF OF SIDNEY REGIONAL MEDICAL CENTER IN CONJUNCTION WITH THE PANHANDLY PUBLIC HEALTH DEPARTMENT (PPHD). PART I, LINE 7: THE COST TO CHARGE RATIO IS DETERMINED AS FOLLOWS: (TOTAL EXPENSES - BAD DEBT)/GROSS PATIENT SERVICE REVENUE = PERCENTAGE OF COST TO CHARGE. PART I, LINE 7G: THERE ARE NO SUBSIDIZED HEALTH SERVICES. PART I, LN 7 COL(F): BAD DEBT EXPENSE OF $1,881,022 HAS BEEN EXCLUDED FROM THE DENOMINATOR IN THE CALCULATION OF THE PERCENTAGES IN LINE 7, COLUMN F. PART II, COMMUNITY BUILDING ACTIVITIES: COMMUNITY SUPPORT INCLUDES ACTIVITIES SUCH AS THERAPISTS AVAILABLE AT GAMES AND AT THE COMMUNITY CENTER AND WELLNESS CAMPAIGNS IN COOPERATION WITH THE COMMUNITY CENTER. LEADERSHIP DEVELOPMENT INCLUDES PROGRAMS DEVELOPED USING TRAINING PROVIDED BY JOE TYE, A PROFESSIONAL FOCUSED IN LEADERSHIP AND VALUES COACHING. COMMUNITY HEALTH IMPROVEMENT INCLUDES COMMUNITY BLOOD DRAWS, HEALTH FAIR, BLOOD PRESSURE SCREENINGS, DIABETES PREVENTION PROGRAMS, AND MULTIPLE SMALLER COMMUNITY EDUCATION PROGRAMS THROUGH RADIO INTERVIEWS WITH HEALTH PROFESSIONALS. PART III, LINE 2: IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE SYSTEM 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. THE SYSTEM 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. PART III, LINE 3: SIDNEY REGIONAL MEDICAL CENTER HAS ESTIMATED THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS WHO MAY HAVE BEEN ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY AT 37.5%. THIS ESTIMATE IS BASED ON A RECOVERY RATE FROM THE COLLECTION AGENCY FOR 2013 ACCOUNTS OF 24.88%. THEORETICALLY, THE NEARLY 25% WHICH HAS BEEN RECOVERED IS BEING RECOVERED FROM PEOPLE WHO COULD PAY BUT DIDN'T. WHEN ESTIMATING THAT POSSIBLY HALF OF THE REMAINING 75% OF THE BAD DEBT WAS ATTRIBUTABLE TO PATIENTS WHO HAD NO MEANS OF PAYMENT RATHER THAN MEANS BUT NO INTENT, THIS ESTIMATE OF FAP AMOUNTS IN BAD DEBT WOULD TOTAL APPROXIMATELY 37.5%. PART III, LINE 4: THE HOSPITAL'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 SYSTEM 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 SYSTEM 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. THE SYSTEM 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.NET PATIENT SERVICE REVENUE:THE SYSTEM HAS AGREEMENTS WITH THIRD-PARTY PAYERS THAT PROVIDE FOR PAYMENTS TO THE SYSTEM 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, THIRD- PARTY PAYERS, AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYERS. 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:THE SYSTEM 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 SYSTEM DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE IN THE COMBINED STATEMENTS OF OPERATIONS. PART III, LINE 8: THE ORGANIZATION USED THE MEDICARE COST REPORT FOR FISCAL YEAR 2013 TO REPORT THE AMOUNTS OF TOTAL REVENUE RECEIVED FROM MEDICARE AND RELATED MEDICARE ALLOWABLE COSTS. MEDICARE PAYS THE HOSPITAL'S RURAL HEALTH CLINICS (RHC) AT COST SUBJECT TO CERTAIN LIMITS. MEDICARE SHORTFALLS IN PAYMENT SHOULD BE CONSIDERED A COMMUNITY BENEFIT AS IT IS PART OF THE HOSPITAL'S MISSION TO PROVIDE THESE SERVICES EVEN IF MEDICARE REIMBURSEMENT IS BELOW COST. PART III, LINE 9B: THE CHARITY CARE POLICY ALLOWS FOR PROACTIVE WRITE OFF TO ALLOWANCE FOR CHARITY CARE OF ANY BALANCE OWED BY A PATIENT KNOWN TO QUALIFY FOR CHARITY CARE UNDER THE FINANCIAL ASSISTANCE POLICY. COLLECTION PROCEDURES DO NOT ENSUE ON ANY ACCOUNTS ELIGIBLE FOR FINANCIAL ASSISTANCE. PART VI, LINE 2: NEEDS ASSESSMENTS ARE DETERMINED THROUGH SCIENTIFIC, AS WELL AS, UNSCIENTIFIC METHODS. EVERY 2 TO 3 YEARS A MARKET ASSESSMENT IS COMPLETED USING CLAIMS DATA WHICH REVEALS THE NEEDS OF COMMUNITY MEMBERS BEING MET ELSEWHERE DUE TO EITHER UNAVAILABILITY OF SERVICE OR PATIENT CHOICE. THIS ASSESSMENT INCLUDES THE DEMOGRAPHICS OF THE AREA WHICH SHOW AN AGING AND MODERATE INCOME POPULATION. THESE FACTS ARE THEN USED TO DETERMINE THE NEEDS OF THE COMMUNITY AS WELL AS THE FUTURE NEEDS BASED ON HISTORICAL DATA. ADDITIONALLY, COMMUNITY NEEDS ARE DETERMINED USING PUBLIC OPINION, PATIENT SATISFACTION RECOMMENDATIONS, BOARD AND LEADERSHIP EXPERIENCE, COMMUNICATIONS WITH COMMUNITY MEMBERS, AND PHYSICIAN INPUT. FUTURE MEASUREMENTS OF HEALTH DATA MINED FROM CLAIMS SUBMISSIONS WILL BE USED TO FURTHER ANALYZE THE NEEDS OF THE COMMUNITY. PART VI, LINE 3: AT THE POINT OF ADMISSION, A PATIENT'S INSURED STATUS IS DETERMINED. PATIENTS WHO ARE UNDERINSURED OR UNINSURED RECEIVE COUNSELING THROUGH THE HOSPITALS PATIENT ADVOCATE AND/OR A MEMBER OF THE FINANCIAL SERVICES STAFF SERVING AS A FINANCIAL COUNSELOR. INFORMATION IS CONVEYED TO THE PATIENT OR THE GUARANTOR REGARDING MEDICAID AND MEDICARE, AS WELL AS CHARITY CARE PROVIDED BY THE HOSPITAL. ADDITIONAL COUNSELING IS PROVIDED AFTER DISMISSAL WHEN THE PROACTIVE APPROACH WAS UNSUCCESSFUL. ADDITIONALLY, SOCIAL SERVICES PERSONNEL HOLD WORKSHOPS AND MEETINGS WITH PATIENTS INDIVIDUALLY REGARDING THEIR COVERAGE IN AN ATTEMPT TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE AND OTHER MEANS FOR THE INDIVIDUALS. PART VI, LINE 4: THE HOSPITAL'S PRIMARY SERVICE AREA (PSA) IDENTIFIES THE GEOGRAPHIC AREA THAT ACCOUNTS FOR 80-90% OF ALL PATIENT VISITS. RESIDENTS OF SRMC'S PSA IN THE PANHANDLE OF WESTERN NEBRASKA COMPRISE 90% OF THE HOSPITAL'S INPATIENT DISCHARGES AND 83% OF ITS ER VISITS. THE PSA POPULATION IS ESTIMATED AT APPROXIMATELY 12,500 WITH A NONEXISTENT GROWTH PATTERN EXPECTED BETWEEN 2009 AND 2014. MEDIAN AGE IN THE PSA IS 40.7, WHICH IS SLIGHTLY YOUNGER THAN THE STATE OF NEBRASKA AT 43.7. SIGNIFICANT GROWTH IS PROJECTED FOR THE AGE GROUP 65+ BETWEEN 2009 & 2014. MEDIAN HOUSEHOLD INCOME IN THE PSA IS COMPARABLE TO THE STATE OF NEBRASKA OVERALL, HOWEVER THERE IS WIDE VARIATION IN MEDIAN HOUSEHOLD INCOME WITHIN THE PSA. PART VI, LINE 5: SPECIFIC TO THE COMMUNITY BUILDING ACTIVITIES THE HOSPITAL CONTRIBUTES THROUGH LEADERSHIP EDUCATION, RESIDENCIES AND SCHOLARSHIPS, IMPROVEMENTS TO FACILITIES, AND COLLABORATION WITH COMMUNITY CLUBS, EMPLOYERS, LEADERS AND THE COMMUNITY CENTER. THE CFO SERVED DURING 2013 AS THE PRESIDENT OF THE FINANCE COMMITTEE FOR PANHANDLE PUBLIC HEALTH AND A BOARD MEMBER OF THE CHAMBER OF COMMERCE WHILE OTHER LEADERS IN THE HOSPITAL PARTICIPATED IN THE CHEYENNE COUNTY LEADERSHIP GROUPS. ROTARY CLUB AND CITY COUNCIL ACTIVITIES AS WELL AS OTHER VOLUNTEER ORGANIZATIONS SAW COLLABORATION FROM THE HOSPITAL AND ITS REPRESENTATIVES. SIDNEY REGIONAL MEDICAL CENTER (SRMC) HOLDS A HOSPITAL SPONSORED COMMUNITY HEALTH FAIR ANNUALLY. SRMC ALSO PROVIDES SMALLER HEALTH CLINICS AT BUSINESSES THROUGHOUT THE COMMUNITY. CHILD OUTREACH FOR NEW MOTHERS, IMMUNIZATION CLINICS, DIABETES EDUCATION, FLU SHOTS AND COMMUNITY WELLNESS ACTIVITIES ARE ACCOMPLISHED THROUGH COLLABORATION WITH SCHOOLS, THE COMMUNITY CENTER, DOCTORS' OFFICES, AND COMMUNITY BUSINESSES AS WELL AS OTHER NOT FOR PROFIT ORGANIZATIONS. SMALL HOSPITALS HAVE BEEN INCREASINGLY CHALLENGED TO MAINTAIN THEIR HISTORICAL SCOPE OF SERVICES, AND MANY HAVE RELUCTANTLY DISCONTINUED PROVIDING OBSTETRICS, CRITICAL CARE, HOME HEALTH AND OTHER SERVICES IMPORTANT TO THE COMMUNITY BUT NOT SUSTAINABLE FROM A FINANCIAL PERSPECTIVE. SRMC HAS BEEN ABLE TO CONTINUE PROVIDING THESE SERVICES AND REMAINS COMMITTED TO DOING SO IN THE FORESEEABLE FUTURE.THE HOSPITAL ORGANIZATION IS PART OF A 'HEALTH SERVICES' COLLABORATION FOCUSING ON THE INITIATIVES ABOVE IN DAILY ROUTINE. THE ORGANIZATION INCLUDES HOME HEALTH AND HOSPICE SERVICES IN COLLABORATION WITH MANY COMMUNITY VOLUNTEERS, WITHOUT WHOM THE SERVICE WOULD NOT BE SUCCESSFUL. EXTENDED CARE SERVICES AS WELL AS ASSISTED LIVING SERVICES ARE OFFERED AS DEPARTMENTAL ENTITIES OF THE HOSPITAL ORGANIZATION. THESE SERVICES ALONG WITH THE HOME HEALTH AND HOSPICE ARE NOT COST BASED REIMBURSED AND, IN FACT, ERODE THE COST BASED REIMBURSEMENT WHICH COULD BE ENJOYED AS A CRITICAL ACCESS HOSPITAL. HOWEVER, THE BOARD OF THE DIRECTORS IS COMMITTED TO PUBLIC HEALTH IN ITS ENTIRETY AND CONTINUES TO SUPPORT ALL HEALTH SERVICES IN THE COMMUNITY. PART VI, LINE 6: SIDNEY REGIONAL MEDICAL CENTER IS NOT PART OF AN AFFILIATED HEALTH CARE ORGANIZATION. X X X X 0 0 0 1 0 0 0 0 0 MICHAEL MATTHEWS MD MEMBER - PHYSICIAN AT LARGE 371510 0 0 0 580 0 0 0 0 0 372090 0 0 0 JAMES THAYER MD MEMBER - CHIEF OF STAFF SURGEON 322178 0 18873 0 1084 0 17500 0 18967 0 378602 0 0 0 KELLY UTLEY CFO 136737 0 0 0 215 0 6055 0 18164 0 161171 0 0 0 MANDY SHAW DOCTOR 409484 0 0 0 227 0 17500 0 0 0 427211 0 0 0 KENNETH MARTIN CRNA 219730 0 0 0 211 0 11243 0 27538 0 258722 0 0 0 DANA HLAVINKA CRNA 219435 0 0 0 145 0 11405 0 23081 0 254066 0 0 0 CALVIN CUTRIGHT DOCTOR 230208 0 0 0 3616 0 0 0 18967 0 252791 0 0 0 CLINTON DORWART DOCTOR 212223 0 0 0 1418 0 8484 0 27538 0 249663 0 0 0 PART I, LINE 5 DR. JAMES THAYER RECEIVES DRAW ON HIS SALARY BASED ON HIS GROSS CHARGES. THE DRAW IS CALCULATED BY MULTIPLYING THE GROSS CHARGES BY 33% AND SUBTRACTING OFF HIS BASE BIWEEKLY SALARY OF $10,000. ADDITIONALLY, HE RECEIVES A BONUS BASED UPON QUALITY INDICATORS, MEDICAL RECORDS COMPLETION, ETC. SCHEDULE J, PART III: JASON PETIK, CEO, RECEIVES COMPENSATION FROM POUDRE VALLEY HEALTH CARE, INC., AN UNRELATED ENTITY. POUDRE VALLEY HEALTH CARE, INC. PROVIDES MANAGEMENT SERVICES TO ITS CLIENTS, INCLUDING THE SIDNEY REGIONAL MEDICAL CENTER. THE SIDNEY REGIONAL MEDICAL CENTER'S BOARD OF DIRECTORS SETS THE SALARY AND BENEFITS FOR MR. PETIK. MR. PETIK RECEIVED $193,519 SALARY, $7,049 RETIREMENT BENEFITS, AND $5,074 NONTAXABLE BENEFITS. MR. PETIK'S SALARY IS REFLECTED IN PART IX, LINE 11A. KEVIN UTLEY EMPLOYEE OF ORGANIZATION AND SPOUSE OF KELLY UTLEY, CFO 61166 EMPLOYEE W-2 WAGES 0 FORM 990, PART VI, SECTION A, LINE 3 POUDRE VALLEY HEALTH CARE, INC. CURRENTLY EMPLOYS THE CHIEF EXECUTIVE OFFICER FOR SIDNEY REGIONAL MEDICAL CENTER. SRMC PROVIDES POUDRE VALLEY HEALTH CARE WITH DATA ON SERVICES PROVIDED TO THE COMMUNITY MONTHLY FOR COMPARISON DATA PURPOSES. FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION'S ACCOUNTING DEPARTMENT PREPARES AN ORGANIZER SUPPLIED BY THE ACCOUNTING FIRM SEIM JOHNSON, LLP AND SUBMITS THE ORGANIZER TO THE ACCOUNTING FIRM FOR THE PREPARATION OF THE FORM 990. COMMUNICATIONS BETWEEN THE ACCOUNTING FIRM AND THE ACCOUNTING DEPARTMENT FINALIZE THE PREPARATION OF THE FORM 990. THE CEO AND CFO THEN REVIEW THE FORM 990 AND E-MAIL IT TO ALL MEMBERS OF THE BOARD OF DIRECTORS FOR THEIR REVIEW. ONCE THE 990 RETURN HAS BEEN APPROVED BY ALL PARTIES IT IS SUBMITTED TO THE IRS ON OR BEFORE THE REGULAR OR EXTENDED DUE DATE. FORM 990, PART VI, SECTION B, LINE 12C EACH YEAR ALL BOARD MEMBERS ARE REQUIRED TO DISCLOSE ANY CONFLICTS OF INTEREST. ANY DUALITY OF INTEREST OR POTENTIAL CONFLICT OF INTEREST ON THE PART OF ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR ANY KEY EMPLOYEE IS DISCLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF RECORD WHENEVER IT ARISES. WHENEVER IT INVOLVES A MATTER OF BOARD ACTION, ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE HAVING A DUALITY OF INTEREST OR A POSSIBLE CONFLICT OF INTEREST IN ANY MATTER DOES NOT VOTE OR ABSTAINS FROM THE VOTE, IF PRESENT IN THE ROOM, ON ISSUES WITH THE CONFLICT EXISTS. OFTEN THE BOARD MEMBER IS ASKED TO LEAVE THE MEETING DURING DISCUSSION PERIODS AND FOR THE VOTE. THESE INDIVIDUALS DO NOT USE THEIR PERSONAL INFLUENCE ON THE MATTERS. FORM 990, PART VI, SECTION B, LINE 15 POUDRE VALLEY HEALTH CARE, INC. PROVIDES ADMINISTRATIVE SERVICES TO SIDNEY REGIONAL MEDICAL CENTER (SRMC). THIS INCLUDES PROVIDING THE HOSPITAL'S CHIEF EXECUTIVE OFFICER. SRMC'S METHOD TO DETERMINE EXECUTIVE SALARY RANGES IS TO ANNUALLY PULL SALARY RANGES FROM NO LESS THAN TWO SURVEY SOURCES (THREE WHEN POSSIBLE) TO DETERMINE THE AVERAGE SALARY RANGE FOR EACH EXECUTIVE POSITION BY GEOGRAPHICAL REGION. THESE ARE REVIEWED AND PRESENTED TO THE HUMAN RESOURCE COMMITTEE OF THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL/RECOMMENDATIONS. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICIES AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. ALSO, THE FINANCIAL STATEMENTS ARE SENT ANNUALLY TO COMMUNITY LEADERS. FORM 990, PART VII, SECTION A, LINE 1A: JASON PETIK RECEIVES COMPENSATION FROM AN UNRELATED ORGANIZATION, POUDRE VALLEY HEALTH CARE INC., WHICH PROVIDES MANAGEMENT SERVICES TO SIDNEY REGIONAL MEDICAL CENTER. FORM 990, PART VII, SECTION A MICHAEL MATTHEWS, MD AND JAMES THAYER, MD ARE PHYSICIANS OF SIDNEY REGIONAL MEDICAL CENTER AND ARE COMPENSATED FOR THE MEDICAL SERVICES THEY PROVIDE. NEITHER IS PAID BY THE HOSPITAL FOR THEIR SERVICE ON THE BOARD OF DIRECTORS. FORM 990, PART IX, LINE 11G PROFESSIONAL FEES - OTHER: PROGRAM SERVICE EXPENSES 2,311,689. MANAGEMENT AND GENERAL EXPENSES 57,442. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,369,131. CONTRACT SERVICES - SURGERY PROFESSIONALS: PROGRAM SERVICE EXPENSES 1,549,372. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,549,372. CONTRACT SERVICES - MEDICAL RECORDS: PROGRAM SERVICE EXPENSES 236,871. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 236,871. FORM 990, PART XI, LINE 2C: THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF SRMC'S FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED SINCE THE PRIOR YEAR. CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION 645 OSAGE SIDNEY NE 69162 470686476 SUPPORT SIDNEY REGIONAL MEDICAL CENTER NE 501(C)(3) LINE 11C, III-FI N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0