2012-05-10T06:14:07-05:00 2011-06-30 BKD LLP 910 E St Louis Street Suite 200 Springfield MO 65806 990 2010-07-01 232449454 Susquehanna Physician Services SUSQ 5703207900 1201 Grampian Boulevard Williamsport PA 17701 Charles J Santangelo 5703213171 2012-05-10 4178658701 2010 2016-02-24 21:20:13Z Susquehanna Health Medical Group Steven P Johnson 777 Rural Avenue Williamsport PA 17701 73261686 0 X www.susquehannahealth.org X 1987 PA To effect a continuum of compassionate care which assures quality for our patients and value for those who provide it. 17 5 616 35 28287 -12372 16638978 13953894 45704434 59307792 0 0 6992124 0 69335536 73261686 0 0 0 0 48781611 54212507 0 0 0 15445870 17574822 64227481 71787329 5108055 1474357 15962836 17038580 10504560 10105947 5458276 6932633 X Susquehanna Physician Services is a subsidiary of Susquehanna Health System(SHS). The mission of SHS and affiliates is as follows: To extend God's healing love by improving the health of those we serve. Our vision is to create a high quality patient centered integrated delivery system. Our values are to demonstrate extraordinary CARE for those who receive our services; share ownership with those who provide our services; and be servant leaders whose behaviors are rooted in quality service, dedicated partnership, responsible stewardship, and commitment to our regional community. 0 0 61166675 54452810 Susquehanna Physician Services (SPS) is comprised of a groupof primary care and specialty physicians. The services primarily serve Lycoming and surrounding counties. For fiscal year ended June 20, 2011there were approximately 525,000 patient visits for SPS. 2869899 4826695 Susquehanna Physician Services operates an outpatient MRI center that services patients from Lycoming and surrounding communities. During the fiscal year ended 6/30/11 the center did 7,690 scans. 64036574 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 616 1 1 1 0 0 0 0 0 0 0 0 0 X 17 5 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 PA X Management 5703268756 1201 Grampian Blvd Williamsport PA 17701 X Steven Johnson 1.00 X X 0 619955 87088 Dr Alexander Nesbitt 40.00 X X 177080 0 26375 Charles Santangelo 1.00 X X 0 310862 23118 Dr George Manchester 1.00 X X 0 307532 31445 Dr Terry Belles 40.00 X X 303807 0 27006 Dr William McCauley 40.00 X X 387005 0 35112 Dr William Pagana 40.00 X 324750 0 24602 Paul Rooney 1.00 X 0 0 0 James Douthat Ed D 1.00 X 0 0 0 Lynda Livingston 40.00 X 0 0 0 Dr William Keenan 40.00 X 171687 0 25784 James Campbell Ed D 1.00 X 0 0 0 Dr Frank Parker 40.00 X 116512 0 25002 Ann Pepperman Esquire 1.00 X 0 0 0 Dr Rene Rigal 40.00 X 390352 0 30186 Dr Susan Branton 40.00 X 502032 0 24580 Dr Stephen Weber 40.00 X 229379 0 22600 Neil G Armstrong 1.00 X 0 275905 23228 James J Turri 40.00 X 217366 0 19407 Dr Sabrina Dowd 40.00 X 635211 0 24572 Dr Ronald E DiSimone 40.00 X 874191 0 24778 Dr Warren L Robinson 40.00 X 762389 0 9898 Dr Edward Wyshock 40.00 X 983858 0 24258 Dr Navin V Barot 40.00 X 780433 0 15431 6856052 1514254 524470 95 0 1 0 McKesson Specialty Care Dist 15212 Collections Center Drive Chicago IL 60693 Pharmacueticals 1064613 Susquehanna Imaging Associates 777 Rural Ave Williamsport PA 17701 MRI Scans 785700 Comphealth Medical Staffing PO Box 972651 Dallas TX 75397 Temporary Employment 388362 ECG Management Consultants 1111 Third Ave Suite 2700 Seattle WA 98101 Consulting Services 301880 Weatherby Locums PO Box 927633 dallas TX 75397 Temporary Employment 298263 14 13953894 13953894 Net Patient Services 621110 46928516 46928516 Inter-Entity SSA 621110 4962098 4962098 MRI Scans 621400 4822298 4822298 Capitation Payments 621110 995299 995299 Inter-Entity Revenue 621110 299199 299199 1300382 1272095 28287 59307792 73261686 59279505 28287 0 6619686 6232681 387005 39078328 35988979 3089349 1893125 1451357 441768 4318116 3919987 398129 2303252 2165383 137869 672980 672980 5014 5014 17280 17280 1584472 1483387 101085 123222 98709 24513 3601552 3528048 73504 338016 311521 26495 2924068 2549442 374626 50089 15117 34972 305226 252062 53164 258858 258858 1766251 707619 1058632 1830037 1818905 11132 Provision For Bad Debt 2092790 2092790 Books Subscriptions Due 283612 242604 41008 Minor Equipment 224084 105061 119023 Equipment Rentals 96547 96547 1400724 976375 424349 71787329 64036574 7750755 0 359647 994199 5171981 6400398 36570 47523 904865 1008511 400000 700000 486150 353777 19808491 12295176 8582766 7513315 20857 20857 15962836 17038580 9632560 9233947 872000 872000 10504560 10105947 X 5458276 6932633 5458276 6932633 15962836 17038580 1474357 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 41973 41973 373321 373321 0 1889503 1042064 847439 13474824 10488579 2986245 4028870 391212 3637658 7513315 Third Party Payors 872000 872000 73261686 71787329 1474357 0 1474357 59307792 0 59307792 13953894 13953894 73261686 71787329 0 71787329 0 71787329 Part X Line 2- Management has evaluated their income tax positions under the guidance included in ASC 740. Based on their review, maanagement has not indentified any material uncertain tax positions to be recorded or disclosed in the financial statements. Part XII Line 4b- Susquehanna Physician Services received financial support from the following related entities The Williamsport Hospital & Medical Center $6,523,797 Divine Providence Hospital $5,436,805 and Muncy Valley Hospital $1,993,292. Central America 0 1 Program Services Captive insurance company 1827759 1 0 1 1827759 0 1827759 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 Steven Johnson 0 487740 0 118573 0 13642 0 72603 0 14485 0 707043 0 0 Dr Alexander Nesbitt 170303 0 5302 0 1475 0 10006 0 16369 0 203455 0 0 0 Charles Santangelo 0 284401 0 20653 0 5808 0 8850 0 14268 0 333980 0 0 Dr George Manchester 0 287407 0 17969 0 2156 0 12525 0 18920 0 338977 0 0 Dr Terry Belles 233481 0 67873 0 2453 0 14036 0 12970 0 330813 0 0 0 Dr William McCauley 353965 0 29665 0 3375 0 16813 0 18299 0 422117 0 0 0 Dr William Pagana 273912 0 50033 0 805 0 8850 0 15752 0 349352 0 0 0 Dr William Keenan 161038 0 0 0 10649 0 8900 0 16884 0 197471 0 0 0 Dr Rene Rigal 349768 0 35000 0 5584 0 16813 0 13373 0 420538 0 0 0 Dr Susan Branton 338397 0 156965 0 6670 0 8850 0 15730 0 526612 0 0 0 Dr Stephen Weber 228420 0 0 0 959 0 10960 0 11640 0 251979 0 0 0 Neil G Armstrong 0 257300 0 15623 0 2982 0 14975 0 8253 0 299133 0 0 James J Turri 195858 0 17395 0 4113 0 12335 0 7072 0 236773 0 0 0 Dr Sabrina Dowd 615906 0 18635 0 670 0 8850 0 15722 0 659783 0 0 0 Dr Ronald E DiSimone 845905 0 0 0 28286 0 8850 0 15928 0 898969 0 0 0 Dr Warren L Robinson 408013 0 305520 0 48856 0 8850 0 1048 0 772287 0 0 0 Dr Edward Wyshock 404425 0 528227 0 51206 0 8850 0 15408 0 1008116 0 0 0 Dr Navin V Barot 556870 0 215747 0 7816 0 0 0 15431 0 795864 0 0 0 Supplemental Information Part III Part I, Line 3: Susquehanna Health System (SHS), EIN # 23-2751183, a related organization, uses the following resources to establish the compensation of the top management officials; compensation committee, independent compensation consultant, written employment contract, compensation survey or study and approval by the board. Supplemental Information Part III Part I, Line 4b: Susquehanna Health System maintains an unfunded deferred compensation plan for the purpose of providing supplemental retirement benefits for Steven P. Johnson. An annual book-entry is recorded consisting of an annual contribution plus interest earnings. For 2010, the amount was $60,077. Dr Ronald Disimone Sign on Bonus X 70000 12557 0 0 1 Dr Navin Barot Sign On Bonus X 50000 34966 0 0 1 47523 Form 990, Part VI, Section A, line 6 Susquehanna Health System, EIN #23-2751183, is the sole member of the governing body Form 990, Part VI, Section A, line 7a Susquehanna Health System, EIN # 23-2751183, may elect or remove members of the governing body. Form 990, Part VI, Section A, line 7b All the business and affairs of the corporation shall be managed and controlled by the Board of Directors, subject to the oversight of the Member of the management and operation of the corporation, except that the following powers are reserved exclusively to the sole Member of the corporation, and no attempted exercise of any such powers by anyone other than the sole Member shall be valid or of any force or effect whatsoever. The sole member shall exercise its power through its Board of Directors. The Member shall have exclusive authority to exercise the following powers: A. To approve the appointment and removal of the President of the corporation. B. To elect and remove, with or without cause, a Director of the corporation. C. To establish the overall policy and long range plans of the corporation,determine or change the mission of the corporation, approve the programs, and services of the corporation, and monitor and maintain the philosophy, goals and purposes for which the corporation was formed and exists. D. To adopt, amend or repeal the Articles of Incorporation or the bylaws. E. To establish requirements for a unified budget, the approval of new capital debt, any increment to any existing capital debt, and/or any change in the capital debt obligations of the corporation. F. To establish requirements for the approval of the acquisition, purchase, sale, leasing outside the ordinary course of business, transfer outside the ordinary cause of business or encumbrance outside the normal course of business of land or buildings and the construction of demolition of buildings owned by the corporation. G. To require a certified audit of corporate funds at any time. H. To approve any guaranty of indebtedness of any person, the granting of any security interest in or the creation of any encumbrance on any asset of the corporation outside the ordinary course of business, or any transfer of any asset of the corporation outside the normal course of business, except transfers between or among affiliated corporations. I. To approve any merger, consolidation, organization, reorganization, joint venture or other modification of corporate structure or affiliations affecting to autonomy, goverance or operations of the corporation. J. To dissolve or terminate the existence of the corporation and determine the distribution of assets upon such termination or dissolution, as provided in the bylaws. K. To appoint annually the external fiscal auditor of the corporation. L. To approve the nominees for elected officers of the Board of Directors of the corporation and to return the list of approved nominees to the Board of Directors for election. M. To remove any elected officer of the corporation. N. To approve the annual capital and operating budget of the corporation. O. To coordinate managed care plans, including decisions concerning entry into or renewal of ay contract or agreement relating thereto. Form 990, Part VI, Section B, line 11 The IRS 990 was first reviewed by an independent accounting firm, then senior management, then with Board members at a combined Susquehanna Health System Finance/Executive/Audit & Compliance committee meeting prior to e-filing. Form 990, Part VI, Section B, line 12c As required by law, SPS policy states that all members of the Board of Managers must sign a statement each year disclosing any conflict of interest that may arise and agree to abstain when issues involving those parties with conflicting interests are called to motion. Any conflicts of interest are reviewed by the System's attorneys. The board of directors, through the Executive Committee, retains an independent outside consultant to provide guidance with respect to the annual establishment of the rebuttable presumption or reasonableness relative to executive compensation and benefits. The consultant annually provides detailed market information from its annual Executive Compensation Survey of Health Systems. In addition, other regional survey data is provided in order to supply the health system with a "national" picture of compensation. With this process established, the executive compensation committee takes the proper steps to educate the Board of Directors to understand all of the above mentioned oversight and to appropriately prepare them for community or media inquiry. In addition, the Board is made aware of the form 990 and its role in the communication of information to the public. Form 990, Part VI, Section C, line 19 The organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. NUMBER REPORTED IN BOX 3 OF FORM 1096 Form 990, Part V, Line 1A All 1099's are issued by Susquehanna Health System, EIN # 23-2751183. All expenses are then allocated back to all related entities. NUMBER OF EMPLOYEES REPORTED ON FORM W-3 FORM 990, PART V, LINES 2A & 2B Susquehanna Health System (SHS), EIN # 23-2751183 utilizes a common paymaster which includes the following entities: Divine Providence Hospital of the Sisters of Christian Charity, EIN # 24-0799343 Muncy Valley Hospital, EIN # 24-0806023 The Williamsport Hospital, EIN # 24-0795508 Susquehanna Health Foundation, EIN # 23-2743470 Susquehanna Physician Services, EIN # 23-2449454 Williamsport Area Ambulance Service Cooperative, EIN # 23-2416166 Providence Cancer Treatment Services, EIN # 23-2925354 The total number of employees reported on Form W-3 would be 3,351 for Susquehanna Health System. Included in that total were 616 employees whose expenses were reported by Susquehanna Physician Services. HOURS FOR RELATED ORGANIZATIONS Form 990, Part VII Section A, Line 1A, Column B Dr. Ronald E. DiSimone works 40 hours per week for Susquehanna Physician Services EIN #23-2449454. In addition he devotes 1 hour per week to Susquehanna Health System EIN #23-2751183. Dr. Alexander Nesbitt works 40 hours per week for Susquehanna Physician Services EIN #23-2449454. In addition he devotes 1 hour per week to the following related organizations: Divine Providence Hospital of the Sisters of Christian Charity 24-0799343 The Williamsport Hospital 24-0795508 Susquehanna Health System 23-2751183 Steven P. Johnson, Charles J. Santangelo, Neil G. Armstrong, and Dr. George A. Manchester work 40 hours per week for the Williamsport Hospital EIN #24-0795508. In addition they devote 1 hour per week to the following related organizations: Divine Providence Hospital of the Sisters of Christian Charity 24-0799343 Muncy Valley Hospital 24-0806023 Susquehanna Health Foundation 23-2743470 Susquehanna Health System 23-2751183 Susquehanna Physician Services 23-2449454 Providence Cancer Treatment Services 23-2925354 The Williamsport Hospital and Medical Center 777 Rural Avenue Williamsport PA 17701 240795508 Hospital PA 501 (c) (3) 3 N/A 0 Divine Providence Hospital of the Sisters of Christian Charity 1100 Grampian Blvd Williamsport PA 17701 240799343 Hospital PA 501 (c) (3) 3 N/A 0 Muncy Valley Hospital 215 East Water Street Muncy PA 17756 240806023 hospital PA 501 (c) (3) 3 N/A 0 Susquehanna Health Foundation 1100 Grampian Blvd Williamsport PA 17701 232743470 Fundraising and affiliated activities PA 501 (c) (3) 11 A I N/A 0 Susquehanna Health System 1205 Grampian Blvd Williamsport PA 17701 232751183 Coordinate & manage the delivery of healthcare PA 501 (c) (3) 11 A I N/A 0 Community Basket LLC 1205 Grampian Blvd Williamsport PA 17701 201195739 Rents real estate PA Susquehanna Health System & Susquehanna Health excluded from tax 0 0 Susquehanna Ventures 1201 Grampian Blvd Williamsport PA 17701 232470263 Pharmacy and infusion services PA N/A C Williamsport Area Ambulance Service Cooperative 1205 Grampian Blvd Williamsport PA 17701 232416166 Ambulance Transport PA N/A C Central PA Provider Network 1205 Grampian Blvd Williamsport PA 17701 232949121 Physicians Insurance PA N/A C Susquehanna Health System Insurance Network LTD PO Box 1159 Grand Caymans CJ KY1-1102 980458722 Captive insurance company CJ N/A 0 0 1 0 0 0 0 0 1 1 0 0 0 1 0 0 0 0