2013-11-15T08:51:27-06:00 2012-12-31 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2012-01-01 390819992 Edgerton Hospital and Health Services Inc EDGE 6088843441 11101 North Sherman Road Edgerton WI 53534 Charles Roeder 6088843441 2013-11-13 1 Kim Hunwardsen CPA P00484560 6122536500 2013-11-13 2012 2016-02-25 16:41:14Z James Pernau 11101 North Sherman Road Edgerton WI 53534 19264814 0 X www.edgertonhospital.com X 1968 WI Serve area communities with exceptional quality and innovative health services 13 12 215 96 0 0 163791 492253 15545480 18729089 -251573 13397 23322 -20058 15481020 19214681 586695 174587 0 0 8402677 9607677 0 0 0 8345601 10629668 17334973 20411932 -1853953 -1197251 32790644 32899272 26553319 27855769 6237325 5043503 X To provide exceptional healthcare for our communities 0 0 16766874 174587 18729089 Edgerton Hospital and Health Services, Inc. is an 18-bed acute care hospital located in Edgerton, Wisconsin.There were 432 total adult admissions in 2012. Total patient days were 3,148 with an average daily census of 8.6 patients. Emergency room and urgent care visits for 2012 were 6,072.Preventive Care Services:Edgerton Hospital and Health Services (Edgerton Hospital) provides several types of free health screenings during the year. These include: blood pressure, dietary counseling and education, diabetes, and cancer screenings.Emergency Room:Edgerton Hospital's Emergency Room is fully staffed 24 hours a day, seven days a week. Edgerton Hospital is affiliated with "Life Flight," a helicopter service that delivers patients to area tertiary care centers. Edgerton Hospital's Urgent Care Center provides another level of walk-in care when appropriate.Community Outreach:Edgerton Hospital works closely with the community to provide hospital and hospital-related services responsive to the specific needs of Edgerton and surrounding farming communities. Edgerton Hospital partners with other city services (such as the police and fire departments) to provide emergency equipment and training necessary to enhance area emergency services. Edgerton Hospital also participates in cooperative emergency response training (with the county and other community services) in preparation for local or area disasters. Community Education:Events are held at the Hospital or conducted by Hospital staff several times a year. In addition, Edgerton Hospital provides targeted outreach to the transient recreational communities within the service area. Charity Care:The Hospital provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than established rates. Because the Hospital does not pursue collection of amounts determined to qualify as charity care, they are not reported as revenue. The amount of charges foregone for services provided under the Hospital's charity care policy was approximately $616,000 for the year ended December 31, 2012. The estimated costs of the charges foregone, based upon an overall cost-to-charge ratio calculation, for the year ended December 31, 2012, was $382,000. 16766874 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 0 1 210 0 1 215 1 0 0 0 0 0 0 0 0 0 0 X 13 12 0 0 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 0 0 WI X Charles Roeder 6088841656 11101 North Sherman Road Edgerton WI 53534 James Schultz 0.30 0.30 X X 0 0 0 Jay Peterson DC 0.30 0.00 X X 0 0 0 Melva Sue Larson 0.30 0.00 X X 0 0 0 Steve Thompson 0.30 0.00 X X 0 0 0 Kamal Muzaffar MD 0.30 0.00 X 0 0 0 Dennis Litsheim MD 0.30 0.00 X 0 0 0 Lawanna Schieldt 0.30 0.00 X 0 0 0 Sara Karman 0.30 0.00 X 0 0 0 Matthew Roethe 0.30 0.00 X 0 0 0 Fred Falk 0.30 0.30 X 0 0 0 Charlie Johnson 0.30 0.00 X 0 0 0 Linda Taplin Statz 0.30 0.00 X 0 0 0 Donald Bice 0.30 0.00 X 0 0 0 James Pernau 40.00 0.30 X 181921 0 19314 Charles Roeder 40.00 0.00 X 143374 0 18296 Todd Crowley 40.00 0.00 X 132625 0 13354 Caryn Oleston 40.00 0.00 X 131475 0 7922 William West MD 40.00 0.00 X 196649 0 14114 786044 0 73000 5 0 1 0 Gilbane Building Co Inc 101 W Pleasant Street 104 Milwaukee WI 53207 Construction management 2170568 Southern Wisconsin Emergency Physicians PO Box 793 Traverse City MI 49685 ER Physicians 1477538 Rock Valley Radiologists PO Box 2103 Janesville WI 53546 Radiology physicians 310000 Stoughton Hospital PO Box 78216 Milwaukee WI 53278 Certified Registered Nurse Anesthetists 235895 Aviand's 1751 W Cty Rd B Roseville MN 55113 Food services management 212706 12 374053 118200 492253 Patient service revenue 622110 18322103 18322103 MEHR Incentive payment 900099 241587 241587 Other supporting revenue 900099 165399 165399 18729089 10300 10300 27003 47061 -20058 -20058 -20058 6169 3072 3097 3097 3097 19214681 18729089 0 -6661 X 174587 174587 365860 365860 7343797 6177329 1166468 85734 71473 14261 1266278 848900 417378 546008 451607 94401 205449 205449 48031 9500 38531 3967910 3365350 602560 128141 3430 124711 702946 455854 247092 230881 227704 3177 60833 34586 26247 117952 51298 66654 1512401 1512401 1812413 1812413 201508 32000 169508 Medical supplies 984838 984838 Provision for bad debts 524039 524039 Dues and subscriptions 122493 23710 98783 9833 5855 3978 20411932 16766874 3645058 0 1536681 2651923 8124 4527 3869810 2791041 278592 326426 140577 149892 27888723 4339414 24909080 23549309 659948 1885721 10641 14069 456577 456577 920614 1069787 32790644 32899272 2647922 1993747 724760 20544515 24545077 3360882 592185 26553319 27855769 X 6226080 5029434 11245 14069 6237325 5043503 32790644 32899272 X -1197251 3429 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 50000 34853 84853 507142 21521573 1697659 20331056 97209 89699 7510 5587122 2552056 3035066 90824 90824 23549309 Estimated third party payor settlements 483000 Construction accounts payable 109185 592185 X Description of Uncertain Tax Positions Under FIN 48: Part X, Line 2: The Hospital is organized as a Wisconsin non-profit corporation and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The Hospital is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, they are also subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose, if applicable. The Organization believes it has appropriate support for any tax positions taken affecting their annual filing requirments, and as such, does not have any uncertain tax positions that are material to the consolidated financial statements. The Organization would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. 1 1 X 1 X 125.000000000000 1 X 225.000000000000 1 1 0 1 1 382000 382000 0.01920 382000 382000 0.01920 31739 7550 24189 0.00120 71982 71982 0.00360 5284169 3221648 2062521 0.10370 2639 2639 0.00010 5390529 3229198 2161331 0.10860 5772529 3229198 2543331 0.12780 0 524039 174662 8131421 8050911 80510 X 1 1 1 1 Edgerton Hospital and Health Services

11101 North Sherman Road Stoughton WI 53534

X X X X Provider based clinic - Milton Clinic Edgerton Hospital and Health Services 1 0 1 1 125.000000000000 1 225.000000000000 1 X X X X X X X 1 1 X X 1 0 X X X X 1 X 0 0 Part I, Line 3c: In addition to providing free or discounted care based on Federal Poverty Guidelines, Edgerton Hospital provides certain accommodations to patients who have trouble paying their bills. These practices include offering uninsured patients a cash discount for prompt payment of the estimated or final charges for services provided. Edgerton Hospital provides interest-bearing loans through H.E.L.P. Financial Inc. Payment arrangements are also available for accounts to be paid within 6 months at no interest. Part I, Line 6a: Edgerton Hospital and Health Services makes its community benefit report available to the public by providing it upon request. Part I, Line 7: Charity care expense was converted to cost on line 7a based on an overall cost-to-charge ratio addressing all patient segments. Community health improvement services, line 7e, health professions education, line 7f, and cash and in-kind contributions, line 7i are reported based on actual expenses recorded in the Organization's general ledger. The cost for subsidized health services reported on line 7g was determined using the Medicare Cost Report. Part I, L7 Col(f): The amount of bad debt expense removed from total expenses to determine the percentage was $524,039. Part III, Line 4: All past due accounts are reviewed to determine if a patient qualifies for charity care, or federal, state, or local assistance. Before an account is written off to bad debt all discounts and payments are applied, including contractual allowances. After every attempt is made to collect the unpaid balance, the account is written off to bad debt. Payments on accounts that were written off as bad debt reduces bad debt expense.A reasonable estimate of the Organization's bad debt expense attributable to patients under the Organization's financial assistance policy is one-third of bad debt expense. Footnote to financial statements:Patient accounts receivable are reduced by an allowance for doubtful accounts. In evaluating the collectability of accounts receivable, the Hospital analyzes its past history and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for doubtful accounts and provision for bad debts. Management regularly reviews data about these major payors sources of revenue in evaluating the sufficiency of the allowance for doubtful accounts. For receivables associated with services provided to patients who have third party coverage, the Hospital analyzes contractually due amounts and provides an allowance for doubtful accounts and a provision for bad debts, if necessary (for example, for expected uncollectible deductibles and copayments on accounts for which the third-party payor has not yet paid, or for payors who are known to be having financial difficulties that make the realization of amounts due unlikely).For receivables associated with self-pay patients (which includes both patients without insurance and patients with deductible and copayment balances due for which third-party coverage exists for part of the bill), the Hospital records a 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 rate (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 8: Edgerton Hospital and Health Services, Inc. is a critical access hospital and therefore did not have a Medicare shortfall in 2012. Total revenue received from Medicare is the gross reimbursement plus settlement. Both total revenue received from Medicare and the Medicare allowable costs are reported from the Medicare Cost Report. The Medicare Cost Report is completed based on the rules and regulations set forth by the Centers for Medicare and Medicaid Services. Part III, Line 9b: Edgerton Hospital and Health Services provides a charitable program consisting of partial or total discounts for those patients who are uninsured, underinsured, and/or unable to pay for necessary healthcare services and are determined eligible to receive such care. As part of the debt collection policy patients are given a written notice after 30 days, 45 days, 60 days, and 70 days. This is followed up by a phone call and if there is no response the account is sent to a pre-collection agency and then the collection agency. For patients known to qualify for charity care or financial assistance, this process is followed for the portion they are responsible for. On accounts which have been assigned to outside collection agencies and are later approved for Community Care, the hospital will request such agencies to cancel and return accounts to the hospital, and to reverse any applicable detrimental credit information created against the patient/guarantor. Edgerton Hospital and Health Services Part V, Section B, Line 12h: Other living expenses and financial obligations relative to household/family size is considered in the calculation for amounts charged to patients. Edgerton Hospital and Health Services Part V, Section B, Line 14g: A summary of the financial assistance policy was made available to the public upon admission, included as a brochure in registration areas, emergency room, and waiting rooms of the Hospital, and is available on our website. Edgerton Hospital and Health Services Part V, Section B, Line 18e: All accounts were reviewed for possible financial assistance prior to sending to a collection agency. Part VI, Line 2: We use the following tools to assess health care needs of the communities we serve: (1) Patient exit questionnaires; (2) Involvement in community groups such as the Edgerton Coalition for a Healthy Community where we assess health needs based upon discussions and topics brought up by the Coalition members; (3) Analysis of data received from the Wisconsin Hospital Association and the Rock County Department of Health; and (4) Utilization of the Intelimed software program which allows us to analyze data from facilities comparable to ours.The data for our Community Health Needs Assessment (CHNA) is complete and we are in the process of writing our CHNA. The CHNA will be presented to the board in November. At that time the implementation strategy will be completed. The CHNA will be posted to our website before December 31, 2013. Part VI, Line 3: A summary of our community care program is listed on our Hospital website and is contained in a brochure that is available to all patients at all registration areas, emergency room, and waiting rooms in the Hospital. The policy is also provided upon admission and upon request. The complete packet of information, along with an application, is given to any patient upon request. Posters which explain our community care program are located in the Emergency Department and inform patients to contact the Business Office for more information. Billing staff discuss the availability of various government benefits, state programs, and assist the patient on how to qualify for such programs where applicable. Part VI, Line 4: Edgerton is located 30 miles south of Madison and 12 Miles north of Janesville on the northern edge of Rock County. Edgerton is in a rural, agricultural area. The 2010 population of Edgerton and Rock County was 5,461 and 160,331 with a projected county growth to 186,331 by 2035. Rock County is dominated by service and manufacturing sectors. The median household income for the county is $49,716, the poverty level is at 12.4% and the population aged 65+ is at 13.8%.There are multiple hospitals within 30 miles of Edgerton including three facilities in Madison, one in Janesville, one in Stoughton and one in Fort Atkinson.Madison Hospitals (30 miles distant)* St.Mary's - 440 bed acute care hospital * Meriter - 448 bed acute care hospital* University of Wisconsin Hospital - 536 bed acute care hospitalOther Hospitals (20 or less miles distant)* Mercy Hospital - Located 12 miles south - 240 bed acute care hospital* Stoughton Hospital - located 12 miles northwest - 35 bed acute care, critical access hospital* Fort Atkinson - Located 17 miles northeast - 82 bed acute care hospital Part VI, Line 5: Edgerton Hospital is an 18-bed critical access hospital located in Edgerton, Wisconsin. Our Board of Trustees is comprised of persons who reside in our primary service area who are not employees of our Organization. The Hospital extends medical staff privileges to all qualified physicians in the community and all surplus funds are reinvested in patient care and plant upgrades. Our Organization is the fiscal agent for the Edgerton Coalition for a Healthy Community and one of our employees is the Project Director of the Coalition. We hold an annual health fair for the community and offer many health related community education classes at little or no cost to the attendees. We provide and staff a First Aid tent at our local community summer festival. Our CEO sits on the Board of Directors of the local Hope Institute of Uganda with meetings held in Janesville, Wisconsin. Reports Filed With States Part VI, Line 7 WI 1 Edgerton Hospital Capital Foundation Inc 11101 North Sherman Road Edgerton WI 53534 203161048 501(c)(3) 171546 Support for operating expenses 1 0 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: Edgerton Hospital provides support to assist with operating expenses for Edgerton Hospital Capital Foundation, Inc. The Foundation must provide documentation of what the funding was used for. X X X 0 0 0 0 0 0 0 0 0 James Pernau 156832 0 0 0 25089 0 3600 0 17194 0 202715 0 0 0 Charles Roeder 117017 0 0 0 26357 0 2385 0 17385 0 163144 0 0 0 William West MD 169187 0 0 0 27462 0 900 0 14530 0 212079 0 0 0 Rock Valley Radiologists Officer and 33.3% owner is a member of the Board 310000 Radiology physician services 0 Form 990, Part VI, Section A, line 1 The Executive Committee consists of the Board Chair, Vice Chair, Secretary, and Treasurer of the Corporation. The Executive Committee has power to transact all regular business of the Corporation during the interim between meetings of the Board of Trustees, except the power to: elect officers of the Corporation, fill vacancies in the Board of Trustees or in the Executive Committee, amend or repeal any provisions of these Bylaws, appropriate funds of the Corporation not included in the budget or exceeding an amount for any one purpose in any one fiscal year fixed or authorized by the Board from time to time, or adopt programs which would involve continuing activity or support by the Corporation for more than one fiscal year. Minutes of the Executive Committee summarizing its actions must be submitted to the Board at its next regularly scheduled meeting. Form 990, Part VI, Section A, line 7a The Board of Trustees consists of two classes: Class E Trustees and Class S Trustees. SSM Health Care of Wisconsin, Inc. has the right to appoint and remove the Class S Trustees. SSM Health Care of Wisconsin, Inc. also has the right to appoint an alternate who will serve instead of a Class S Trustee with voting rights if the Class S Trustee is unable to attend a meeting of the Board of Trustees. Form 990, Part VI, Section B, line 11 The Form 990 is provided to the Trustees of the Board before it is filed. The return is reviewed by the Accounting Manager and CFO. Form 990, Part VI, Section B, line 12c Board members, officers, and employees complete and sign a conflict of interest policy annually. The employee handbook contains a conflict of interest policy. The Board Chair and CEO review the potential conflicts of Board members and the HR department reviews the potential conflicts of employees. Potential conflicts may include but are not limited to ownership or control of an entity that contracts with Edgerton Hospital. Board members with conflicts are restricted from voting on such matters and the conflict is made a matter of record in the minutes. Form 990, Part VI, Section B, line 15a The Board determines compensation for the CEO. It is based on an annual performance review and comparability data. The Board provides substantiation of the deliberation and decision for the compensation process. The process is completed annually and was last completed in 2012. The CEO determines the salary of the CFO based on comparability data. Form 990, Part VI, Section C, line 19 The Organization's governing documents, conflict of interest policy, and financials statements are available to the public upon request. The financial statements are also attached to the Form 990. Other Fees Form 990, Part IX, line 11g Equipment repair, rental and service agreements: Program service expenses 1,135,051. Management and general expenses 323,604. Fundraising expenses 0. Total expenses 1,458,655. Physician and consulting fees: Program service expenses 1,793,626. Management and general expenses 95,659. Fundraising expenses 0. Total expenses 1,889,285. Contract fees and purchased services: Program service expenses 436,673. Management and general expenses 183,297. Fundraising expenses 0. Total expenses 619,970. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Decrease in net assets of Edgerton Memorial Community Hospital Auxiliary 3,429. Edgerton Hospital Capital Foundation Inc 11101 North Sherman Road Edgerton WI 53534 203161048 Provide financial support for Edgerton Hospital and Health Services, Inc. WI 501(c)(3) Line 11a, I Edgerton Hospital and Health Services Inc 1 0 1 1 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0 Edgerton Hospital Capital Foundation Inc C 374053 General ledger Edgerton Hospital Capital Foundation Inc B 171546 General ledger