2014-05-08T07:48:15-05:00 2013-06-30 550486667 Arnett Foster Toothman PLLC P O Box 2629 Charleston WV 25329 990 2012-07-01 556005561 Webster County Memorial Hospital WEBS 3048475682 324 Miller Mountain Drive Webster Springs WV 26288 Annette Keenan 3048475682 2014-05-02 1 Dale Carpenter P00189642 3043460441 2012 2015-11-30 17:44:51Z Annette Keenan 324 Miller Mountain Drive Webster Springs WV 26288 15457296 0 X www.webstercountymemorialhospital.net X 1951 WV To provide acute short-term care to residents of Webster and surrounding counties of West Virginia. 7 7 185 4 0 0 203454 87856 13640686 14245606 9605 51508 467762 1072326 14321507 15457296 0 0 0 0 7364977 8295465 0 0 0 5467151 6663393 12832128 14958858 1489379 498438 3927524 4462430 1935086 1971554 1992438 2490876 The mission of Webster County Memorial Hospital is to provide excellent, high quality care in a compassionate and cost-effective manner. 0 0 11730255 14245606 Critical Access Hospital services provided included 612 inpatient days, 28,457 outpatient visits, and 14,205 RHC visits. Charges forgone for charity amounted to $248,179. 11730255 1 1 0 0 0 0 0 0 0 0 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 10 0 1 185 1 0 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X Julie Clutter 3048475682 324 Miller Mountain Drive Webster Springs WV 26288 Elsworth Sonny Helmick 2.00 X 0 0 0 Larry Lynch 2.00 X 0 0 0 John Leslie 2.00 X 0 0 0 Betsy Morris 2.00 X 0 0 0 Cathy Morton McSwain 2.00 X 0 0 0 Carol Cogar 2.00 X 0 0 0 Mary Anne Carpenter 2.00 X 0 0 0 Annette Keenan 40.00 X 134336 0 1816 John Blake 40.00 X 217271 0 2774 Luke McElwain 40.00 X 243008 0 1554 Todd Lares 40.00 X 230010 0 1674 Robert Mace 40.00 X 291296 0 2274 Steven Craft 40.00 X 183497 0 734 1299418 0 10826 12 0 1 0 0 24300 63556 63556 87856 Patient Service Revenue 624100 14245606 14245606 14245606 51508 51508 5061 0 5061 5061 5061 Pharmacy 446110 892193 892193 Cafeteria 722210 16165 16165 158907 158907 1067265 15457296 14245606 0 1123834 139198 103758 35440 6167271 4597083 1570188 25030 18657 6373 1481040 1103968 377072 482926 359973 122953 107979 107979 942213 702326 239887 15214 15214 1116017 831879 284138 136903 102047 34856 151875 113208 38667 27928 20818 7110 37373 27858 9515 391810 292055 99755 161664 120504 41160 Bad debt expense 2217301 2217301 0 Medical supplies 638154 475680 162474 Charity care expenses 248179 248179 0 Provider tax 170683 170683 300100 224278 75822 14958858 11730255 3228603 0 290707 293673 1853514 1950147 258621 338032 78717 91831 6048132 4660572 1274658 1387560 110271 157440 61036 243747 3927524 4462430 1395556 1554386 539530 417168 1935086 1971554 X 1978633 2485532 13805 5344 1992438 2490876 3927524 4462430 498438 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 32757 32757 1776692 1620830 155862 4072377 3001953 1070424 166306 37789 128517 1387560 Third party settlements 243747 243747 13044194 52378 52378 12991816 2465480 2465480 15457296 12545756 52378 52378 12493378 2465480 2465480 14958858 Part XI, Line 2d - Other Adjustments: Expenses netted against income on financial statements 52,378. Part XI, Line 4b - Other Adjustments: Bad debts netted against income on financial statements 2,217,301. Charity care netted against income on financial statements 248,179. Part XII, Line 2d - Other Adjustments: Expenses netted against income on financial statements 52,378. Part XII, Line 4b - Other Adjustments: Bad debts netted against income on financial statements 2,217,301. Charity care netted against income on financial statements 248,179. 1 1 X 1 X 1 X 150.000000000000 1 1 0 1 1 134265 134265 0.01050 645667 537062 108605 0.00850 779932 537062 242870 0.01900 28823 28823 0.00230 28823 28823 0.00230 808755 537062 271693 0.02130 1 1199560 3423127 3423127 X 1 1 1 1 Webster County Memorial Hospital

PO Box 312 Webster Springs WV 26288

X X X Rural Health Clinic Webster County Memorial Hospital 1 1 X X X X X X X X 11 1 0 1 X X X X 0 0 1 1 150.000000000000 1 150.000000000000 1 X X X X X X X 1 1 X X X 1 0 X X X X 1 0 0 Part I, Line 3c: The patient's income is considered and reviewed to determine the amount of discount they receive, if not free care. The patient's assets are also reviewed. They can only have one vehicle and one house. If the patient has more than one vehicle, the total of the vehicles cannot be more than $2,000. If they total more than $2,000, the patient will automatically be reduced to a percentage less than 100%. Part I, Line 7: The cost to charge ratio as calculated from worksheet 2 was used to determine community benefit expenses for all subsidized health services. Part I, Line 7, Column (f): The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 2217301. Part III, Line 4: Patient accounts receivable are carried at the original charge less an estimate made for doubtful or uncollectible accounts. The allowance is based upon a review of the outstanding balances aged by financial class. Management uses collection percentages based upon historical collection experience to determine collectibility. Management also reviews troubled, aged accounts to determine collection potential. Patient accounts receivable are written off when deemed uncollectible. Recoveries of accounts previously written off are recorded as a reduction to bad debt expense when received. Interest is not charged on patient accounts receivable.The cost to charge ratio as calculated from worksheet 2 was used to determine bad debt expense. Part III, Line 8: Medicare cost report was used to report Medicare revenue and expenses.Any shortfall should be treated as a community benefit. Part III, Line 9b: Patient's are informed about the finanical assistance program when they call to ask about their medical bills. The billers offer the patient information about the program over the phone or if the patient is seen by the biller in person, they are shown the application and the documents that are needed. Webster County Memorial Hospital Part V, Section B, Line 3: We consulted all available community members willing to fill out our questionnaire. Then we took all that information and reviewed it and made changes as we could, such as hiring two more providers and changing our advertising. We also offered a couple of more services. Webster County Memorial Hospital Part V, Section B, Line 5c: We took needs assessments to areas in community where multiple people are at such as lodges, heath fairs and senior centers. We also had report available in hospital for patients. Webster County Memorial Hospital Part V, Section B, Line 7: We reviewed all of the input given to us and changed what we could, such as communication, waiting times, recruited and added two more ER doctors, and lined parking lot. Patients wanted things like more parking, surgeons and OB which we cannot do due to limited space. We did consult regarding telemedicine to get services we do not offer available here. Other issues we had were patients not aware of financial assistance and updated equipment and those things were going to be addressed in advertising. Webster County Memorial Hospital Part V, Section B, Line 12h: All patients are charged the same price for all services in our charge master, for all noninsured and insured patients. Once the Business Office receives the financial assistance application, we look at the patient's total income and assets for the household. We then go by the FPG times 150% and determine the patient's eligibility. Webster County Memorial Hospital Part V, Section B, Line 14g: Patient's were given applications during our county's health fair. Webster County Memorial Hospital Part V, Section B, Line 18e: The patient is sent the 5 statements and if they don't make a payment or contact the billing office, the billing department of Webster County Memorial Hospital will review their accounts manually and determine if the patient received the 5 statements or made any payments. Then the account will be sent to collections. Part VI, Line 2: Director of Clinical Operations & Quality continuously reviews referral logs made by secretaries to see if there is any services we can provide here. Then we find out cost and reimbursement issues and present to CEO. Part VI, Line 3: If the patient presents to the registration desk and is private pay, they are told by the registration staff of the program. They are then offered an application and told that they need to provide the documentation on the application to the billing department. If the patient is private pay and is admitted to the hospital as IP or OBS, the Social Worker meets with the patient and provides them an application and goes over the information needed to apply. Part VI, Line 4: Our geographical service area is rural. Population of our county is 9,043. Residents have an average income of $25,990 with 24.3% being below the Federal Poverty Guidelines. We are the only hospital serving the community and the next nearest facility is 40 miles away. Part VI, Line 5: 1) Governing body is comprised of members of all areas who are not employees of organization. 2) We extend privileges to all qualified staff working for facility. 3) We apply surplus funds into providing new services for patients. 4) Emergency Room is available to all patients whether they have ability to pay or not 5) We offer MRI, Cardiac and Pulmonary Rehab and Nuclear medicine that is not available at any other location in county. 6) We offer charitable care which has increased this year due to patient education, serve the communtiy and have volunteers that help. List of States receiving Community Benefit Report Part VI, Line 7 WV 1 X X 0 0 0 0 0 0 0 0 0 John Blake 217271 0 0 0 0 0 500 0 3290 0 221061 0 0 0 Luke McElwain 243008 0 0 0 0 0 1554 0 1230 0 245792 0 0 0 Todd Lares 230010 0 0 0 0 0 0 0 2970 0 232980 0 0 0 Robert Mace 291296 0 0 0 0 0 0 0 3369 0 294665 0 0 0 Steven Craft 183497 0 0 0 0 0 0 0 1994 0 185491 0 0 0 X 1 63556 Cost of donated property 0 0 0 Form 990, Part VI, Section B, line 11 During a regularly scheduled board meeting, each board member receives a copy of the completed Form 990. The board will vote and approve the completed form before filing. Form 990, Part VI, Section B, line 12c Officers and Directors are required to complete an annual conflict of interest questionnaire. This questionnaire is then reviewed by the Board of Trustees, annually, for any interests that could give rise to conflicts. If a conflict should arise, the individual would have to disclose this conflict to the Board of Trustees. The board member would not be permitted to vote on the issue, if applicable. Form 990, Part VI, Section B, line 15 To determine compensation of the Organization's CEO, the organization compares Forms 990 of other organizations, reviews written employment contracts and performs compensation surveys of similar facilities. A review of compensation is conducted internally by the Board of Trustees. Form 990, Part VI, Section C, line 19 The Organization's governing documents, conflict of interest policy and financial statements are made available upon request.