2013-05-14T15:06:49-05:00 2012-06-30 KPMG LLP 191 West Nationwide Blvd Ste 500 Columbus OH 432152568 990 2011-07-01 263956318 HSHS MEDICAL GROUP INC % KEITH MOORE HSHS 2175234747 3215 Executive Park Drive SPRINGFIELD IL 62703 Keith Moore 2013-01-23 true KPMG LLP 6142492300 2011 2016-02-24 21:20:13Z X DR Frank Mikell 3215 EXECUTIVE PARK DRIVE SPRINGFIELD IL 62703 86308475 false 0928 X N/A X 2008 IL TO REVEAL AND EMBODY CHRIST'S HEALING LOVE FOR ALL PEOPLE THROUGH A HEALTH CARE MINISTRY BY PROVIDING PRIMARY AND SPECIALTY PHYSICIAN SERVICES TO THE COMMUNITIES HOSPITAL SISTERS HEALTH SYSTEM SERVES. 7 4 792 4 0 0 0 34000485 41143217 51245021 -176172 5575 242530 973610 41209575 86224691 0 0 0 0 63010871 70745840 0 0 0 23688421 29868629 86699292 100614469 -45489717 -14389778 17106895 26743998 13343794 7207685 3763101 19536313 X TO REVEAL AND EMBODY CHRIST'S HEALING LOVE FOR ALL PEOPLE THROUGH A HEALTH CARE MINISTRY BY PROVIDING PRIMARY AND SPECIALTY PHYSICIAN SERVICES TO THE COMMUNITIES HOSPITAL SISTERS HEALTH SYSTEM SERVES. false false 86152860 51925 SEE SCHEDULE O 86152860 true false false false false false false false false false true false false true true true false true false false false false false false false false false false false true false false false false false false false false false false false false true true false false false false true 100 0 792 true false false false false false false false false false false false X 7 4 false false false false true true true true true false false true true true true true true true true false X KEITH MOORE 2175234747 3215 EXECUTIVE PARK DRIVE SPRINGFIELD IL 62703 X FRANK L MIKELL MD 2.5 X X 0 718147 119424 LAWRENCE SCHUMACHER 2.5 X X 0 722931 254068 Mary Starmann-Harrison 2.5 X X 0 832934 188038 John Slayton 1.0 X 0 0 0 Jimmie Lansford 1.0 X 0 0 0 Lon Blaser DO 1.0 X 0 0 0 James Burgett 1.0 X 0 0 0 SONIA MEHTA MD 30.0 X X 0 131340 11200 KEITH JANKUSKI 37.5 X 227914 0 46698 Keith Moore 37.5 X 222884 0 57918 Ann MCarr 0.25 X 0 225812 215561 Joseph Yazdi 40.0 X 1382300 0 45040 Nicholas Poulos 40.0 X 946740 0 49680 Omid Ghalambor 40.0 X 1284414 0 45261 Terrence Pencek 40.0 X 1019634 0 68685 Upendra Sinha 40.0 X 723122 0 64681 STEPHANIE MCCUTCHEON 0.0 X 0 841644 0 5807008 3472808 1166254 137 true true false KIARA CLINICAL INTEGRATION NETWORK 4936 LAVERNA ROAD SPRINGFIELD IL 62707 allscripts pm & EMR 2992430 Navigant Consulting 4511 Paysphere Circle CHICAGO IL 60674 consulting services 416113 Relay Health PO Box 403421 ATLANTA GA 303843421 Claims Software 304206 The Oursource Group 39867 Treasury Center CHICAGO IL 606949800 Collection services 303416 Dell Marketing LP PO Box 802816 CHICAGO IL 606802816 Web Design 261361 23 34000485 34000485 NET PATIENT SERVICE REVENUE 900099 51245021 51245021 51245021 89359 89359 0 0 83784 -83784 -83784 0 -83784 0 0 0 MISCELLANEOUS 900099 208858 208858 REFERENCE LAB 900099 764752 764752 973610 86224691 52218631 0 5575 0 0 0 0 221208 0 221208 0 58583589 53348815 5234774 0 8896657 7792170 1104487 3044386 2639274 405112 101907 36907 65000 250717 50979 199738 7150 0 7150 0 0 0 8572461 5692004 2880457 447500 52588 394912 4639715 3818442 821273 2253200 1061398 1191802 0 3718904 3298549 420355 163419 90302 73117 0 147393 5939 141454 0 0 403736 47056 356680 3400654 3089029 311625 BAD DEBT 4273344 4181141 92203 0 AMORTIZATION 672502 263609 408893 0 EQUIPMENT EXPENSES 410348 361838 48510 0 MISCELLANEOUS 118260 101573 16687 0 287419 221247 66172 100614469 86152860 14461609 0 4273497 5863104 -3572853 6095874 0 0 10855336 8432917 0 0 0 0 0 0 13624 0 269998 208046 4326556 710241 3337923 3616315 0 0 0 0 0 0 0 0 1929370 2527742 17106895 26743998 1467462 962675 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11876332 6245010 13343794 7207685 X 3763101 19536313 0 0 0 0 3763101 19536313 17106895 26743998 X -14389778 30162990 X false true true X true true X X X false false false ST ELIZABETH'S HOSPITAL BELLEVILLE ILLINOIS 370663567 03 true 0 ST JOSEPH'S HOSPITAL BREESE ILLINOIS 371208459 03 true 0 ST JOSEPH'S HOSPITAL HIGHLAND ILLINOIS 370663568 03 true 0 ST JOSEPH'S HOSPITALL CHIPPEWA FALLS WISCONSIN 390810545 03 true 0 ST MARY'S HOSPITAL DECATUR ILLINOIS 370661244 03 true 0 ST MARY'S HOSPITAL STREATOR ILLINOIS 362169181 03 true 0 ST MARY'S HOSPITAL GREEN BAY 390818682 03 true 0 ST ANTHONY'S HOSPITAL EFFINGHAM ILLINOIS 370661233 03 true 0 ST FRANCIS HOSPITAL LITCHFIELD ILLINOIS 370661236 03 true 0 ST JOHN'S HOSPITAL SPRINGFIELD ILLINOIS 370661238 03 true 0 ST VINCENT'S HOSPITAL GREEN BAY WISCONSIN 390817529 03 true 0 SACRED HEART HOSPITAL EAU CLAIRE WISCONSIN 390807060 03 true 0 ST NICHOLAS HOSPITAL SHEBOYGAN WISCONSIN 390808480 03 true 0 13 0 0 1246880 491814 755066 3079676 218427 2861249 0 0 0 3616315 WORK IN PROGRESS 1044310 DUE FROM AFFILIATES 1418091 OTHER ASSETS,NET 60608 LICENSES 4733 2527742 0 ACCRUED PAYROLL LIABILITIES 5649428 DUE TO AFFILIATES 1256937 OTHER CURRENT LIABILITIES 470192 INTERCOMPANY LIABILITIES -1131547 6245010 ASC 740-10 On July 1, 2007, HSHS adopted ASC Subtopic 740-10, Accounting for Uncertainty in Income Taxes - an Interpretation of FASB Statement No. 109. ASC Subtopic 740-10 addresses the determination of how tax benefits claimed or expected to be claimed on a tax return should be recorded in the consolidated financial statements. Under ASC Subtopic 740-10, HSHS must recognize the tax benefit from an uncertain tax position only if it is more likely than not that the tax position will be sustained on examination by the taxing authorities, based on the technical merits of the position. The tax benefits recognized in the consolidated financial statements from such a position are measured based on the largest benefit that has a greater than 50% likelihood of being realized upon ultimate settlement. ASC Subtopic 740-10 also provides guidance on derecognition, classification, interest, and penalties on income taxes, accounting in interim periods and requires increased disclosures. At the date of adoption, and as of June 30, 2012 and 2011, HSHS does not have a liability for unrecognized tax benefits. X true true X X X X X X true true false false false false false false false FRANK L MIKELL MD 0 604272 0 0 0 113875 0 101313 0 18171 0 837631 0 76885 LAWRENCE SCHUMACHER 0 676477 0 0 0 46454 0 239154 0 15734 0 977819 0 100520 KEITH JANKUSKI 200771 0 0 0 27143 0 23985 0 23533 0 275432 0 0 0 Keith Moore 210382 0 0 0 12502 0 39851 0 18773 0 281508 0 0 0 Ann MCarr 0 180382 0 0 0 45430 0 197622 0 18652 0 442086 0 15440 Mary Starmann-Harrison 0 622223 0 0 0 210711 0 135349 0 53257 0 1021540 0 0 STEPHANIE MCCUTCHEON 0 0 0 0 0 841644 0 0 0 0 0 841644 0 0 Joseph Yazdi 1362264 0 20000 0 36 0 24115 0 21745 0 1428160 0 0 0 Nicholas Poulos 946704 0 0 0 36 0 32381 0 18119 0 997240 0 0 0 Omid Ghalambor 1282516 0 0 0 1898 0 21262 0 25339 0 1331015 0 0 0 Terrence Pencek 1019598 0 0 0 36 0 50119 0 19166 0 1088919 0 0 0 Upendra Sinha 723086 0 0 0 36 0 47409 0 18092 0 788623 0 0 0 Social Club Dues Schedule J, Part I, Line 1a HSHS Medical Group, inc. paid Keith Jankuski's social club dues during the year. The personal portion of the membership expense was included in his reportable compensation. STEPHANIE MCCUTCHEON SCHEDULE J, PART I, LINE 4A STEPHANIE MCCUTCHEON RECEIVED A SEVERANCE PACKAGE DURING THE YEAR IN THE AMOUNT OF $823,075 FOR HER SERVICES AS PRESIDENT AND CEO OF HOSPITAL SISTERS HEALTH SYSTEM. ANN M. CARR SCHEDULE J, PART I, LINE 4B ANN M. CARR PARTICIPATED IN A SERP DURING THE YEAR IN THE AMOUNT OF $33,655. LAWRENCE SCHUMACHER SCHEDULE J, PART I, LINE 4B LAWRENCE SCHUMACHER PARTICIPATED IN A SERP DURING THE YEAR IN THE AMOUNT OF $92,988. MARY STARMANN-HARRISON SCHEDULE J, PART I, LINE 4B MARY STARMANN-HARRISON PARTICIPATED IN A SERP DURING THE YEAR IN THE AMOUNT OF $96,913. FRANK MIKELL SCHEDULE J, PART I, LINE 4B FRANK MIKELL PARTICIPATED IN A SERP DURING THE YEAR IN THE AMOUNT OF $111,653. SONIA MEHTA SCHEDULE J, PART I, LINE 4B SONIA MEHTA PARTICIPATED IN A SERP DURING THE YEAR IN THE AMOUNT OF $7,529. Programs Services Form 990, Part III, Line 4A HSHS Medical Group is the physician organization of Hospital Sisters Health System ("HSHS"), a health care ministry of the Catholic Church. As a mission-based organization, it is our desire to connect with all who seek care, healing, and hope. Primarily the mission is filled through patient access of primary care providers, including family medicine, internal medicine, and pediatrics. To ensure access to health care for all, a Charity Care policy has been implemented for all practices of the HSHS Medical Group. The Charity Care policy helps ensure that all who come to us will receive quality care, and are treated with respect and compassion. The HSHS Medical Group Charity Care policy provides patients with an opportunity to qualify for financial assistance when receiving non-elective services. The level of charity care assistance for which any person is eligible is based, in part, on their income compared to the current year Federal Poverty Guidelines. To qualify for Charity Care, a person completes a two-part Income Test. Part One determines that no other governmental or private insurance is available to the person. Part Two follows a process to determine the charity amount in relationship to the person's/family's income. The HSHS Medical Group Charity Care program is based on the current year Federal Poverty Guidelines ("FPG") issued by the Department of Health & Human Services annually and published in the Federal Register. An FPG and Charity Allowance Table is updated annually by the HSHS Medical Group and is used to determine whether the person qualifies for charity care and, if so, at what level. The amount is determined by multiplying the allowance level specified in the table by total charges calculated using the rate of 150% of the Medicare allowable charge for each item or service rendered during the visit based on the applicable Medicare locality. RIGHTS OF MEMBERS TO ELECT GOVERNING BODY FORM 990, PART VI, LINES 6 & 7A THE SENIOR GOVERNING BODY OF HSHS MEDICAL GROUP, INC. (THE "CORPORATION") IS THE MEMBER OF THE CORPORATION, WHICH IS HOSPITAL SISTERS SERVICES INC,("HSSI"), AN ILLINOIS NOT FOR PROFIT CORPORATION EXEMPT FROM FEDERAL TAXATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. PURSUANT TO SECTION 2.3 OF THE CORPORATION'S BYLAWS, HSSI HAS THE RIGHT TO APPOINT AND REMOVE THE CORPORATION'S BOARD OF DIRECTORS, CHAIRPERSON OF THE BOARD, AND PRESIDENT. MEMBER RESERVED POWERS FORM 990, PART VI, LINE 7B Responsibility for the policy and operations of HSHS Medical Group, Inc. (the "Corporation") is vested in its Board of Directors, except with respect to specific powers reserved in the Corporation's Bylaws to the Corporation's Member, which is Hospital Sisters Services, Inc. ("HSSI"). The governance and operations of the Corporation are subject to HSSI's exclusive right to exercise these reserved powers with respect to Corporation and organizations of which the Corporation is either, directly or indirectly, a controlling member or a controlling shareholder ("Affiliates"). The reserved powers include all rights granted to HSSI by law and the right to: (a) Adopt, approve amendments to, or amend any statement of philosophy, mission, mission integration, or values or any name, logo, or mark of the Corporation or of any Affiliate; (b) Adopt, approve amendments to, or amend the Articles of Incorporation of the Corporation or of any Affiliate; (c) Adopt, approve amendments to, or amend the Bylaws of the Corporation or of any Affiliate; (d) Appoint and remove the Board of Directors, any one or more of the Directors of the Corporation or of any Affiliate, and the Chairperson and President of the Corporation or of any Affiliate; (e) Approve the recommendation of the Board of Directors to appoint or remove the Board of Directors, any one or more Directors of the Corporation or of any Affiliate, and the Chairperson and President of the Corporation or of any Affiliate. (f) With respect to the Corporation or any Affiliate, approve the purchase, sale, alienation, exchange, lease, or encumbrance of any real property of the Corporation or of any Affiliate, which property has a value in excess of limits set from time to time by the Member; (g) Approve the operating and capital budgets of the Corporation or of any Affiliate, and any deviations by the Corporation or any Affiliate from such budgets in an amount or percentage specified by the Member from time to time; (h) Approve the strategic plan and goals of the Corporation or of any Affiliate; (i) Approve the sale of substantially all of the assets of the Corporation or of any Affiliate; (j) Approve the merger or dissolution of the Corporation or of any Affiliate; (k) Adopt or amend the plan for ministry education and governance for the Corporation and its Affiliates; (l) Approve the Corporation's Mission Accountability Reports and those of any Affiliate; (m) Approve the financial policies and procedures of the Corporation or of any Affiliate and approve any deviations from such policies and procedures by the Corporation or any Affiliate; (n) Adopt policies to implement the Reserved Powers of the Member; (o) Outside the budgeting process of the Corporation, approve or amend changes to a substantial part or all of the price list or chargemaster of the Corporation for patient services; and (p) Adopt and amend employee and independent contractor template agreements and compensation ranges, plans, policies and methodologies (including the awarding of any incentive compensation) and benefits. FORM 990 REVIEW PROCESS FORM 990, PART VI, LINE 11B THE organization EMPLOYS KPMG TO ASSIST IN THE OVERALL PREPARATION, REVIEW AND ELECTRONIC SUBMISSION OF ITS FORM 990. KPMG PROVIDES GUIDANCE iN IDENTIFYING CRITICAL ERRORS IN THE RETURN SUBMISSION, AND FEEDBACK ON QUANTITATIVE AND QUALITATIVE RESPONSES. ADDITIONALLY, THE organization CFO PERFORMS A THOROUGH REVIEW OF THE RETURN, AND REVIEWS IT WITH THE organization CEO AND/OR SENIOR LEADERS BEFORE PRESENTING IT IN ITS ENTIRETY TO THE organization's BOARD FOR QUESTIONING AND REVIEW PRIOR TO THE RETURN'S SIGNING AND SUBMISSION TO THE IRS. CONFLICT OF INTEREST POLICY FORM 990, PART VI, LINE 12C The organization is subject to the corporate compliance program and conflict of interest policy ("policy") of Hospital Sisters Health System, an Illinois not for profit corporation exempt from federal taxation under section 501(c)(3) of the internal revenue code. A REVISED CORPORATE COMPLIANCE PROGRAM AND CONFLICT OF INTEREST POLICY HAVE BEEN usED SINCE JANUARY, 2009 TO establish the practice of managing CONFLICTS OF INTEREST USING A SYSTEM-WIDE PROTOCOL FOR DISCLOSURE STATEMENTS. IN ACCORDANCE WITH the organizaton's CONFLICT OF INTEREST POLICY, ALL COVERED PERSONS HAVE A DUTY TO COMPLY WITH THE CONFLICT OF INTEREST POLICY FOR ANY CONTRACT, TRANSACTION, RELATIONSHIP, OR ACTIVITY CONTEMPLATED, ENTERED INTO, OR CONDUCTED AT HSHS OR ITS AFFILIATES. THE POLICY DEFINES COVERED PERSONS AS BOARD MEMBERS, BOARD COMMITTEE MEMBERS, OFFICERS, BOARD DESIGNEES, SENIOR MANAGEMENT, MEMBERS OF ANY COMMITTEE THAT OVERSEES THE APPROVAL OF PHARMACEUTICALS AND MEDICAL DEVICES, AND ANY OTHER INDIVIDUAL WHO HOLDS A POSITION OF TRUST. ON AN ANNUAL BASIS, HSHS DISCLOSES A COPY OF THE CONFLICT OF INTEREST POLICY (AND ALL CORRESPONDING PROCEDURES, GUIDELINES, FORMS, AND TOOLS) TO ALL COVERED PERSONS, AND ADVISES ALL COVERED PERSONS IN WRITING OF ANY SUBSTANTIVE CHANGES TO THIS POLICY AND SUCH RELATED MATERIALS. COVERED PERSONS ARE REQUIRED TO REVIEW AND COMPLETE THE CORRESPONDING CONFLICT OF INTEREST STATEMENT. THE SYSTEM OFFICE VICE PRESIDENT - SYSTEM RESPONSIBILITY, VICE PRESIDENT - RISK & COMPLIANCE, OR MEMBERS OF THE AUDIT AND INTEGRITY COMMITTEE ("COMMITTEE") ARE AVAILABLE TO ANSWERS ANY QUESTIONS A COVERED PERSON MAY HAVE. IN ADDITION, IF, AT ANY TIME AFTER SUBMITTING AN ANNUAL CONFLICT OF INTEREST STATEMENT, A COVERED PERSON BECOMES AWARE OF AN INTEREST THAT HE OR SHE WOULD HAVE HAD TO DISCLOSE AT THE ANNUAL INTERVAL, THE COVERED PERSON IS REQUIRED PROMPTLY TO DISCLOSE THE INTEREST TO THE COMMITTEE USING THE HSHS CONFLICT OF INTEREST DISCLOSURE STATEMENT. COMPLETED CONFLICT OF INTEREST STATEMENTS ARE SUBMITTED TO THE COMMITTEE, WHICH IS RESPONSIBLE FOR IDENTIFYING, ASSESSING, AND MANAGING CONFLICTS OF INTEREST THAT ARISE IN THE COURSE OF CONDUCTING THE AFFAIRS OF HSHS AND ITS AFFILIATES. IF THE COMMITTEE DETERMINES THAT A CONFLICT OF INTEREST EXISTS, THE CONFLICT OF INTEREST POLICY REQUIRES HSHS NOT TO ENGAGE IN, OR ENTER INTO, A PROPOSED CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY UNLESS THE COMMITTEE OR, WHERE NECESSARY, THE BOARD OF DIRECTORS (ACTING THROUGH ITS DISINTERESTED MEMBERS), HAS INVESTIGATED ALTERNATIVES TO THE PROPOSED CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY AND, IN THE ABSENCE OF ALTERNATIVES THAT ARE IN THE BEST INTERESTS OF HSHS, HAS DETERMINED: 1. THAT, REGARDLESS OF WHETHER THE COVERED PERSON PARTICIPATES IN THE IMPLEMENTATION OF THE PROPOSED CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY; 2. THE CONTRACT, TRANSACTION, ARRANGEMENT, OR ACTIVITY IS IN THE BEST INTERESTS OF HSHS; 3. THE CONTRACT, TRANSACTION, ARRANGEMENT, OR ACTIVITY IS FAIR AND REASONABLE FROM THE PERSPECTIVE OF HSHS; AND 4. HSHS CANNOT OBTAIN A MORE ADVANTAGEOUS CONTRACT, TRANSACTION, ARRANGEMENT, OR ACTIVITY WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES. IN DETERMINING WHETHER A CONTRACT, TRANSACTION OR ARRANGEMENT IS FAIR and reasonable to HSHS, THE COMMITTEE SHALL CONSIDER, WHERE APPLICABLE: 1. APPRAISALS OR OTHER INDEPENDENT VALUATIONS OF THE FAIR MARKET VALUE OF THE CONTRACT, TRANSACTION, OR ARRANGEMENT; 2. INFORMATION REGARDING COMPARABLE CONTRACTS, TRANSACTIONS, OR ARRANGEMENTS BETWEEN UNRELATED PARTIES; 3. OFFERS FROM COMPARABLE COMPETING ENTITIES; AND/OR 4. STUDIES OF COMPARABLE COMPENSATION ARRANGEMENTS. IN ANY CASE IN WHICH THE COMMITTEE FINDS, AFTER TAKING THE STEPS DESCRIBED ABOVE, THAT HSHS SHOULD PARTICIPATE IN A PROPOSED TRANSACTION OR ARRANGEMENT DESPITE THE EXISTENCE OF A CONFLICT OF INTEREST, THE COMMITTEE SHALL DEVELOP, IMPLEMENT, MONITOR, AND ENFORCE COMPLIANCE WITH A CONFLICT MANAGEMENT PLAN FOR MANAGING THE CONFLICT OF INTEREST AS IT CONSIDERS NECESSARY FOR SUCH FINDINGS TO REMAIN VALID THROUGHOUT THE LIFE OF THE CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY. ALL CONFLICT MANAGEMENT PLANS SHALL: 1. STATE THAT THE COMMITTEE WILL OVERSEE, MONITOR, AND ENFORCE COMPLIANCE WITH THE PLAN THROUGHOUT THE COURSE OF THE STUDY AND SPECIFY MEANS FOR DOING SO, INCLUDING, WITHOUT LIMITATION, THAT THE APPROPRIATE INDIVIDUALS MUST PROVIDE THE COMMITTEE WITH WRITTEN REPORTS PERTAINING TO COMPLIANCE WITH THE CONFLICT MANAGEMENT PLAN, THAT THE COMMITTEE SHALL HAVE THE RIGHT TO AUDIT THE STUDY FOR SUCH COMPLIANCE, AND THE RIGHT TO IMPOSE SANCTIONS FOR NON-COMPLIANCE; 2. STATE THAT THE PLAN MUST BE SHARED WITH COVERED PERSON WHOSE INTERESTS IT WAS DEVELOPED TO MANAGE; 3. STATE THAT THE PLAN MUST BE SHARED WITH, AND PERIODIC REPORTS ON COMPLIANCE WITH THE PLAN MUST BE PROVIDED TO, THE BOARD, SENIOR MANAGEMENT, AND/OR GOVERNMENT AGENCIES; AND 4. PROVIDE FOR SUCH OTHER MANAGEMENT STEPS AND MECHANISMS THE COMMITTEE CONSIDERS NECESSARY AND APPROPRIATE. IN ADDITION TO THE COMMITTEE, THE SYSTEM OFFICE VICE PRESIDENTS OF SYSTEM RESPONSIBILITY AND RISK & COMPLIANCE MAY RETAIN SUCH INDEPENDENT ADVISORS OR EXPERTS AS DEEMED NECESSARY TO ASSIST IN MAKING ITS DETERMINATIONS AND DECISIONS. IF THE COMMITTEE DETERMINES THAT THE CONTEMPLATED TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY CANNOT PROCEED DUE TO A CONFLICT OF INTEREST, THE COMMITTEE SHALL INFORM THE APPLICABLE COVERED PERSON OR DECISION-MAKING BODY OF SUCH DETERMINATION WITHIN ONE WEEK OF THE COMMITTEE MEETING AT WHICH THE CONTEMPLATED TRANSACTION WAS DISCUSSED. THE COMMITTEE SHALL DOCUMENT ITS REJECTION OF THE CONTEMPLATED TRANSACTION IN THE COMMITTEE'S MEETING MINUTES. WHISTLEBLOWER POLICY FORM 990, PART VI, LINE 13 Provisions within the corporate compliance program and conflict of interest policy provide protections for whistleblower type activities. COMPENSATION PROCESS FORM 990, PART VI, LINE 15 HSHS MEDICAL GROUP, INC. Did NOT COMPENSATE its CEO. HOWEVER, THE CEO IS COMPENSATED BY A RELATED ORGANIZATION, HOSPITAL SISTERS HEALTH SYSTEM ("HSHS"). HSHS MEDICAL GROUP, INC. DEFERS TO THE HSHS COMPENSATION POLICY FOR DETERMINATION OF COMPENSATION FOR THE CEO. THE HSHS COMPENSATION POLICY IS AS FOLLOWS: THE COMPENSATION COMMITTEE ("COMMITTEE") IS COMPRISED OF INDEPENDENT MEMBERS OF THE BOARD OF DIRECTORS. THE COMMITTEE DEVELOPS A COMPENSATION PHILOSOPHY FOR THE SYSTEM AND ALL AFFILIATES. THE COMMITTEE SELECTS AND HIRES THE INDEPENDENT COMPENSATION CONSULTANT TO DEVELOP COMPARABILITY DATA AND ADVISE THE COMMITTEE DURING ITS DELIBERATIONS REGARDING ALL ELEMENTS OF TOTAL COMPENSATION FOR ALL DISQUALIFIED INDIVIDUALS. INTEGRATED HEALTHCARE STRATEGIES ("IHS"), THE CONSULTANTS UTILIZED BY THE COMMITTEE, USE DATA FROM MULTIPLE TAX-EXEMPT PEER GROUP SOURCES TO DETERMINE SALARY RANGES, INCENTIVE OPPORTUNITY RANGES AND BENEFITS FOR THE DISQUALIFIED INDIVIDUALS. IHS THEN ASSISTS THE COMMITTEE IN PREPARING CONTEMPORANEOUS DOCUMENTATION OF ALL ACTIONS. EACH COMMITTEE MEETING IS CONDUCTED WITH THE INTENT TO CREATE A REBUTTABLE PRESUMPTION OF REASONABLENESS FOR ALL ELEMENTS OF EXECUTIVE TOTAL COMPENSATION FOR THE DISQUALIFIED INDIVIDUALS. THE CHAIRMAN MAKES THIS DECLARATION AND ALSO INQUIRES IF THERE ARE ANY CONFLICTS OF INTEREST BY ANY ATTENDEES. ANY CONFLICTS ARE DISCLOSED AND THE COMMITTEE THEN ACTS IN A MANNER TO AVOID ANY CONFLICTED INDIVIDUAL PARTICIPATING IN ANY MANNER WHERE A CONFLICT MIGHT EXIST. AT THE END OF THE MEETING, THE COMMITTEE PREPARES CONTEMPORANEOUS MINUTES THAT RECORD ALL ACTIONS TAKEN DURING THE MEETING. DOCUMENTS AVAILABLE TO THE PUBLIC FORM 990, PART VI, LINE 19 The governing documents and conflict of interest policy are available to the general public upon request. COMPENSATION ARRANGEMENT FORM 990, PART VII, SECTION A HOSPITAL SISTERS HEALTH SYSTEM EMPLOYS THE MANAGEMENT/OFFICERS OF THE WHICH ARE CENTRALLY SUPPORTED FOR THE BENEFIT OF THE THIRTEEN HOSPITALS IT SPONSORS. POOLED INVESTMENT FUND FORM 990, PART X, LINE 2 THE ORGANIZATION'S CASH RESERVES ARE INVESTED IN A POOLED INVESTMENT ACCOUNT MAINTAINED BY HOSPITAL SISTERS HEALTH SYSTEM ("HSHS"). PARTICIPATION IN THE POOLED INVESTMENT FUND IS LIMITED TO THE 501(C)(3) HOSPITALS AND HEALTH SERVICES ORGANIZATIONS SPONSORED BY HSHS. THE POOLED ACCOUNT CONSISTS OF CASH, EQUITY AND DEBT SECURITIES THAT ARE PUBLICLY TRADED. IN ACCORDANCE WITH THE PROVISIONS OF STATEMENT OF FINANCIAL ACCOUNTING STANDARDS ("SFAS") NO. 124, "ACCOUNTING FOR CERTAIN INVESTMENTS HELD BY NOT-FOR-PROFIT ORGANIZATIONS", INVESTMENTS IN EQUITY SECURITIES WITH READILY DETERMINABLE FAIR VALUES AND ALL INVESTMENTS IN DEBT SECURITIES ARE REPORTED AT FAIR VALUE ON THE BALANCE SHEET. INCOME, REALIZED AND UNREALIZED GAINS AND LOSSES ARE POOLED AND ALLOCATED TO THE PARTICIPANTS. INDIVIDUAL COMPONENTS OF ASSETS AND REVENUE ARE NOT IDENTIFIED TO THE INDIVIDUAL HOSPITAL PARTICIPANTS. Other Change In Net Assets or Fund Balances 990 Part XI, Line 5 Transfer From Affiliates 30,077,999 ACCRUED BENEFIT LIABILITY 84,990 ---------- Total Other Change in Net Assets 30,162,990 =========== AFFILIATED HEALTH SYSTEM DISCLOSURE HSHS Medical Group, Inc. is an affiliate of Hospital Sisters Health System (HSHS), a health care ministry that includes 13 hospitals, scores of community-based health centers and clinics, and more than 2,000 physician partners across Illinois and Wisconsin. The Mission of HSHS is to reveal and embody Christ's healing love for all people through our high quality Franciscan health care ministry. We live our Mission by healing those who seek our care, as well as through our Community Benefit initiatives. Working collaboratively with others in the 12 communities we serve, our Community Benefit efforts are successfully expanding access to care, improving the health status of residents, and furthering medical education and knowledge. Across HSHS, we collectively provided $174.2 million in Community Benefits (or 9.7% of total hospital expenses) in FY2012. Included in this amount was $43.1 million provided for Charity Care and $97.9 million for unreimbursed care provided under the Medicaid program. In addition, HSHS hospitals committed significant resources to care for Medicare patients. The cost of providing services to primarily elderly beneficiaries of the Medicare program - in excess of governmental and managed care contract payments - was $168.4 million. HSHS hospitals also recorded $106.6 million in uncollectible accounts. Beyond the dollars invested in our Community Benefit programs, HSHS also continues to reinvest any surplus revenue from operations and investments into new medical technology, facility infrastructure and health care services in our communities. By doing do, we ensure we are able to meet the ongoing demand for high quality, efficient and easily accessible health care. Recognizing that the health care delivery model in the U.S. is evolving, HSHS remains focused on implementing our Care Integration strategy. Care Integration coordinates the delivery of care around the needs of each patient. During FY2012, we made significant progress with this strategy as we further implemented interoperable health information technologies, expanded the number of Medical Homes, and strengthened our alignment with physicians. Greater access to care As a Franciscan health care ministry, HSHS is deeply committed to serving those who are most in need. We not only provide care to every patient who walks through our doors, but also reach out beyond the walls of our hospitals and clinics to care for the individual. Our efforts to ensure residents in the communities we serve receive the right care at the right time often involve partnering with others to achieve this goal. Across our two-state system, there are numerous examples of HSHS collaborating with other organizations to enhance access to care for those in need. In western Wisconsin, St. Joseph's Hospital in Chippewa Falls works closely with the Chippewa Health Improvement Partnership (CHIP) to support the Open Door Clinic. The free medical clinic provides health care for those without insurance coverage. This past year, the clinic received a total of 2,216 patient visits, a 25% increase from the prior year. With more than 150 individuals volunteering, the clinic provided over 6,500 hours (including 700 physician hours and 1,500 nursing hours) of service to individuals. The Open Door Clinic is an example of HSHS providing leadership and support to a community-based program designed to meet the needs of those less fortunate. In northeastern Wisconsin, St. Vincent Hospital in Green Bay supports patient care for the uninsured at the NEW Community Clinic by paying a nurse's salary and offering free and discounted laboratory and radiology services. More than 70% of patients who use the clinic report the care they received helped keep them out of the Emergency Department. St. Nicholas Hospital in Sheboygan proactively reaches out to local Hmong and Hispanic organizations to ensure these populations can participate in free screenings and health education programs. Through this ongoing outreach initiative, St. Nicholas engaged more than 350 people last year, and in many cases was able to identify critical health conditions early and provide appropriate follow-up care. A Woman's Place at St. Mary's Hospital Medical Center in Green Bay reaches out to Hispanic neighbors to provide health and wellness education, health screenings, resources and referral services. Last year A Woman's Place touched the lives of more than 7,000 women through health screenings, educational events, classes and its resource center. In southeast Illinois, area residents can get help filling a prescription through the long-term collaboration between St. Anthony's Memorial Hospital in Effingham and Catholic Charities. Last year, St. Anthony's helped underwrite the cost of prescription medications for more than 430 residents. In southwest Illinois, St. Joseph's Hospital in Highland recognized many rural residents did not have a reliable means of transportation and partnered with generous individuals in the community to offer a free transportation service. The "Friends' Van," fully supported by the Friends of St. Joseph's Hospital, provides free rides to medical, dental and other personal appointments within a 20-mile radius of Highland. In FY2012, the Friends Van transported 2,050 individuals for a total of 12,561 miles. In addition to programs such as these, HSHS makes sure that those who need financial assistance for care receive it. Our Charity Care program covers 100% of hospital charges for individuals and families who earn less than 200% of the federal poverty level. HSHS Charity Care programs have a sliding scale, in some instances providing up to a 60% discount on charges for those earning up to 600% of the federal poverty level. Counselors are available in our hospitals to explain our charity care policies to patients, provide them with assistance in filling out a simple application form, or help them enroll in publicly funded health care programs. Better community health As part of our mission to embody Christ's healing love, we understand that we have a responsibility to improve the overall quality of life in our communities by supporting initiatives that promote health and wellness. We recognize we are most successful when we work together with a wide array of public and private organizations that share our commitment to improving lives. By doing so, we maximize our efforts and reduce the duplication of services. HSHS hospitals also understand we need to listen closely to the residents of the communities we serve to ensure the health care needs of all are being met. To that end, each of our 13 hospitals completed Community Health Needs Assessments (CHNA) during FY2012. The information gathered from these assessments is being used to help us develop new, and enhance existing, programs and services that best address the needs of the community. Among the many priority needs identified from the CHNAs include metabolic and cardiovascular disease management, adequate food and nutrition, and mental health. HSHS hospitals are addressing these and other needs by proactively offering educational opportunities, preventative screenings, and new or enhanced clinical services. To address metabolic disease management, St. Francis Hospital in Litchfield, Illinois, partners with Montgomery County Health Department to provide screening for diabetes and renal disease. St. Francis Hospital teams up with Macoupin County Health Department to provide Diabetes Self-Management classes. St. Joseph's Hospital in Breese, Illinois coordinates several community education seminars and health fairs on cardiovascular disease and healthy eating each year. Over 3,000 residents participated in these health events last year. Recognizing the importance of proper food and nutrition to overall health, St. John's Hospital in Springfield initiated the Destination Dinner program which teaches families how to cook healthy, from-scratch meals, and eat together as a family. Families meet quarterly to learn new cooking skills. They also learn how to prepare a meal for a family of four on a budget of $8.00. In addition to raising awareness about how to eat healthy on a limited budget, the program brings families together around the dinner table, which research shows promotes healthy relationships, increased academic performance and decreased risk for substance abuse and risky sexual behavior. Sacred Heart Hospital in Eau Claire, Wisconsin addressed the need for access to mental health services for children and adolescents by opening an outpatient behavioral health clinic. Sacred Heart has also adopted screening tools for behavioral and mental health risk factors for use at affiliated clinics. HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:FRANK L. MIKELL, M.D. TITLE:vice chairperson HOURS:58 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:LAWRENCE SCHUMACHER TITLE:Chairperson HOURS:58 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Mary Starmann-Harrison TITLE:Secretary HOURS:58 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:SONIA MEHTA, M.D. TITLE:President HOURS:30 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Ann M.Carr TITLE:Treasurer HOURS:60 Springfield Health Partners LLC 4936 Laverna Road springfield IL 62707 371364419 healthcare IL 0 0 HSHS MG Kiara Clinical Integration Network LLC 4936 Laverna ROAd springfield IL 62707 261417684 healthcare IL 0 0 HSSI Physician Clinical Integration Network 4936 Laverna Road Springfield IL 62707 371668647 Healthcare IL 0 0 KCIN HOSPITAL SISTERS HEALTH SYSTEM 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371058692 HEALTHCARE IL 501(C)(3) 11A NA false HOSPITAL SISTERS OF ST FRANCIS FDTN 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371186514 HEALTHCARE IL 501(C)(3) 11A NA false HSHS SELF INSURANCE TRUST 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371120626 INSURANCE IL 501(C)(3) 11A NA false HOSPITAL SISTERS HEALTHCARE WEST INC 2661 COUNTY HIGHWAY 1 CHIPPEWA FALLS WI 54729 510157933 HEALTHCARE WI 501(C)(3) 11A NA false HSHS HEALTH CARE PLAN TRUST FUND 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371137724 HEALTHCARE IL 501(C)(9) N/A NA false HOSPITAL SISTERS SERVICES INC 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371163402 HEALTHCARE IL 501(C)(3) 11A NA false SACRED HEART HOSPITAL 990 WEST CLAIREMONT AVE EAU CLAIRE WI 54701 390807060 HEALTHCARE WI 501(C)(3) 3 NA false ST ANTHONY'S HOSPITAL 503 N MAPLE STREET EFFINGHAM IL 62401 370661233 HEALTHCARE IL 501(C)(3) 3 NA false ST ELIZABETH'S HOSPITAL 211 SOUTH THIRD STREET BELLEVILLE IL 62220 370663567 HEALTHCARE IL 501(C)(3) 3 NA false ST NICHOLAS HOSPITAL 3100 SUPERIOR AVENUE SHEBOYGAN WI 53081 390808480 HEALTHCARE WI 501(C)(3) 3 NA false ST JOHN'S HOSPITAL 800 EAST CARPENTER STREET SPRINGFIELD IL 62769 370661238 HEALTHCARE IL 501(C)(3) 3 NA false ST JOSEPH'S HOSPITAL 9515 HOLY CROSS LANE PO BOX BREESE IL 62230 371208459 HEALTHCARE IL 501(C)(3) 3 NA false ST JOSEPH'S HOSPITAL 2661 COUNTY HIGHWAY 1 CHIPPEWA FALLS WI 54729 390810545 HEALTHCARE WI 501(C)(3) 3 NA false ST MARY'S HOSPITAL 1800 E LAKE SHORE DRIVE DECATUR IL 62521 370661244 HEALTHCARE IL 501(C)(3) 3 NA false ST MARY'S HOSPITAL 111 SPRING STREET STREATOR IL 61364 362169181 HEALTHCARE IL 501(C)(3) 3 NA false ST MARY'S MEDICAL CENTER 1726 SHAWANO AVENUE GREEN BAY WI 54303 390818682 HEALTHCARE WI 501(C)(3) 3 NA false ST VINCENT HOSPITAL 835 S VAN BUREN GREEN BAY WI 54301 390817529 HEALTHCARE WI 501(C)(3) 3 NA false ST JOSEPH'S HOSPITAL 1515 MAIN STREET HIGHLAND IL 62249 370663560 HEALTHCARE IL 501(C)(3) 3 NA false ST FRANCIS HOSPITAL 1215 FRANCISCAN DRIVE LICHFIELD IL 62506 370661236 HEALHCARE IL 501(C)(3) 3 NA false HSHS WICONSIN MEDICAL GROUP INC 3215 EXECUTIVE PARK DRIVE SPRINGFIELD IL 62703 264545959 HEALTHCARE WI 501(C)(3) 11A NA false ORANGE CROSS AMBULANCE INC 919 ASHLAND AVENUE SHEBOYGAN WI 53081 391860942 HEALTHCARE WI 501(C)(3) 3 ST NICHOLAS false WISCONSIN UPPER PENINSULA ONCOLOGY MGMT 835 S VAN BUREN GREEN BAY WI 54301 391677100 HEALTHCARE WI 501(C)(3) 3 ST VINCENT false UNITY LIMITED PARTNERSHIP 2366 OAK RIDGE CIRCLE DE PERE WI 54115 391750729 HEALTHCARE WI 501(C)(3) 11A HSSI false Memorial and St Elizabeth's Healthcare 4000 North Illinois Street Swansea IL 62226 371312961 HealthCare IL St Elizabeth's RELATED 0 0 false 0 false 0.00000 Prairie Heart Institute - Carbondale LL 800 East Carpenter Street Springfield IL 62769 371321197 HealthCare IL St John's RELATED 0 0 false 0 false 0.00000 Northeast Wisconsin Radiation Therapy Se 1821 S Webster Avenue Suite 300 Green Bay WI 543079047 263749065 HealthCare WI HSSI RELATED 0 0 false 0 false 0.00000 Pain Center of Wisconsin 4131 W Loomis Road Suite 300 Greenfield WI 53221 263155343 HealthCare WI St Vincent RELATED 0 0 false 0 false 0.00000 Surgery Center of Sheboygan LLC 3141 Saemann AveNUE Sheboygan WI 53081 260822209 HealthCare WI St Nicholas RELATED 0 0 false 0 false 0.00000 Prevea Ventures LLC 2710 EXECUTIVE DRIVE Green Bay WI 54304 203775127 HealthCare WI HSSI RELATED 0 0 false 0 false 0.00000 Carpenter Street Hotel 525 North Sixth Street springfield IL 62702 364128127 hotel IL lasante inc RELATED 0 0 false 0 false 0.00000 Springfield Urgent Care Real Estate LLC PO Box 19456 springfield IL 627949456 030413258 rent. real es IL lasante inc RELATED 0 0 false 0 false 0.00000 Kiara Inc 4936 Laverna ROAd Springfield IL 62707 371163401 HealthCare IL HSHS C Corp 0 0 0.00000 LaSante Wisconsin Inc 4936 Laverna ROAd Springfield IL 62707 391572196 HealthCare IL Kiara Inc C Corp 0 0 0.00000 LaSante Inc 4936 Laverna ROAd Springfield IL 62707 371163400 HealthCare IL Kiara Inc C Corp 0 0 0.00000 Prairie Cardiovascular 619 East Mason Suite 4P57 Springfield IL 62701 371071858 HealthCare IL Kiara Inc C Corp 0 0 0.00000 Prevea Health Services 2710 EXECUTIVE DRIVE Green Bay WI 54304 391839351 HealthCare WI HSSI C Corp 0 0 0.00000 Prevea Clinic Inc 2710 EXECUTIVE DRIVE Green Bay WI 54304 391839349 HealthCare WI HSSI C Corp 0 0 0.00000 Prevea Health Network 2710 EXECUTIVE DRIVE Green Bay WI 54304 392000537 HealthCare WI HSSI C Corp 0 0 0.00000 RENAISSANCE QUALITY INSURANCE LTD PO BOX 1159 Grand Cayman Cayman Islands CJ KY1-1102 980669963 Insurance CJ HSSI C CORP 0 0 0.00000 true true true true false false false false true false false true true true true true true true TRANSACTIONS WITH RELATED ORGANIZATIONS SCHEDULE R, PART V, LINE 1 THE HSHS MEDICAL GROUP ("THE GROUP") MANAGES THE OPERATIONS OF VARIOUS PHYSICIAN MEDICAL PRACTICES WHICH ARE OWNED BY HSHS HOSPITALS. THE GROUP PROVIDES ACCOUNTING, PAYROLL, HR, BILLING AND MANAGEMENT SERVICES FOR THE PRACTICES. THE GROUP EMPLOYS THE PROVIDERS AND THE STAFF, PROCESSES PATIENT BILLING AND PAYS THE EXPENSES OF THE PRACTICES. THE OPERATING PROFIT/LOSSES OF THE PRACTICES ARE ASSESSED BACK TO THE SPONSORING HOSPITAL ON A MONTHLY BASIS. EACH MONTH, CASH IS TRANSFERRED FROM EACH HOSPITAL TO OR FROM THE GROUP BASED ON THE NET INCOME OR LOSS FOR THE HOSPITALS PRACTICES THAT MONTH. TRANSACTIONS WITH RELATED ORGANIZATIONS Schedule R, Part V, Line 2 ANY TRANSACTIONS LISTED ON SCHEDULE R, PART V, LINE 1 AND NOT ON SCHEDULE R, PART V, LINE 2 ARE BETWEEN RELATED 501(C)(3) AND DO NOT REQUIRE REPORTING ON THIS SECTION.