2012-06-29T14:49:41-05:00 2011-12-31 990 2011-01-01 411713783 FAIRVIEW RED WING HEALTH SERVICES FAIR 6512675000 P O BOX 95 - 701 FAIRVIEW BLVD RED WING MN 55066 Scott Wordelman 6512675000 2012-06-29 2011 2016-02-24 21:20:13Z Scott Wordelman 701 Fairview Blvd Red Wing MN 55066 97224992 0 X www.redwing.fairview.org X 1905 MN Fairview Red Wing Health Services provides health care services and promotes healthcare in the service area. This includes medical education, research and scientific investigations related to health and medicine. Provided care to 2,576 inpatients for a total of 4,867 patient days. Provided treatment for 10,309 emergency room visits and provided a total of 148,815 clinical encounters. 13 7 797 170 0 0 295650 0 92279136 92445259 1971194 4579249 182584 184181 94728564 97208689 0 0 0 0 56319395 55772186 0 0 0 37249557 38000756 93568952 93772942 1159612 3435747 141319167 140582095 72994891 68822072 68324276 71760023 X Fairview Red Wing Health Services exists to deliver exemplary care to the whole person, encompassing body, mind and spirit, at every stage of life. See Schedule OWe will be unrelenting in our responsiveness to patients, customers and the communities we serve, and will inspire excellence, innovation and compassion at every opportunity. 0 0 80997554 92445259 Fairview Red Wing Medical Center combines a clinic and hospital into one state-of-the-art facility. Opened in 2001, the medical center has a 30-bed inpatient hospital care unit that includes intensive care and a birthing center. Clinic services include: primary family services, specialty medical and specialty surgical services, urgent and emergency care and rehabilitation services. This medical center also offers the latest in diagnostic tools, i.e. CT scan, MRI and full lab services. Red Wing Medical Center is a complete health care facility for patients throughout Goodhue and Pierce counties. In 2011, the medical center provided care to 2,576 inpatients for a total of 4,867 patient days. Provided treatment for 10,309 emergency room visits and provided a total of 148,815 clinical encounters. 80997554 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 11 0 1 797 1 0 1 CJ 0 0 0 0 0 0 X 13 7 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 MN X X MIKE LARSON 6512675000 P O BOX 95 - 701 FAIRVIEW BLVD RED WING MN 55066 David D Murphy 5.00 X 0 0 0 Jeffrey Ketcham M D 40.00 X X 622425 0 31499 Silas B Foot III 5.00 X 0 0 0 Jack Alexander M D 40.00 X X 252549 0 31592 Amy DeJong M D 40.00 X X 219699 0 30405 Barbara Haley 5.00 X 0 0 0 John O Hanson 5.00 X 0 0 0 Paula Phillippe 5.00 X 0 478288 72123 John Doherty 5.00 X 0 394760 51957 Robert Riegelman 5.00 X 0 0 0 Jennifer Beck 5.00 X 0 0 0 Theodore R Thompson M D 5.00 X 0 0 0 Scott R Wordelman 40.00 X X 0 378387 22497 Michael Larson 40.00 X 220710 0 30051 Nancy Dimunation 40.00 X 160379 0 23233 Matthew A Eich M D 40.00 X 622666 0 30267 Everett M Hughes 40.00 X 606268 0 31499 Michael R Johnson 40.00 X 518674 0 14349 Christopher McDevitt 40.00 X 418072 0 31499 3641442 1251435 400971 75 0 1 0 Central Minnesota Diagnostics Inc 150 10th Street NW Milaca MN 56353 Radiology Services 816725 McKesson Info Solutions 5995 Windward Parkway Alpharetta GA 30005 Software Services 725316 Midwest Surgical Services 5575 West Old Shakopee Rd Ste 90 Bloomington MN 55437 Ophthalmology Service 454080 University of Minnesota Physicians 720 Washington Ave SE Minneapolis MN 55414 Physicians 374634 Dell Marketing LP P O Box 802816 Chicago IL 60680 Computer Services 280293 11 Patient care 621110 90178420 90178420 Medical Services 621990 1810650 1810650 Cafeteria 722210 208237 208237 Miscellaneous Rev 561439 149340 149340 Laboratory 621500 98612 98612 92445259 4589031 4589031 184181 184181 184181 184181 6521 16303 -9782 -9782 -9782 97208689 92445259 0 4763430 45130688 40346906 4783782 2441330 2241375 199955 5377629 4807609 570020 2822539 2476550 345989 1905201 1856983 48218 187500 187500 7111778 4559145 2552633 579933 382263 197670 1735951 1279697 456254 43633 43633 259517 209490 50027 3675702 3670077 5625 4331546 3457577 873969 Supplies 9234525 9156346 78179 Bad Debt 4179968 4179968 Taxes 2579649 690816 1888833 Util, Repairs & Mainten 1433276 1049527 383749 742577 589592 152985 93772942 80997554 12775388 0 -763046 38726 13296985 13507022 250440 250440 1135743 1153042 406853 437861 86997725 43534697 44541979 43463028 71221413 70981420 11228800 10750556 141319167 140582095 9344916 5817538 60190707 60722965 3459268 2281569 72994891 68822072 X 68316777 71748755 7499 11268 68324276 71760023 141319167 140582095 3435747 0 X 0 1 0 X 0 X 1632275 1632275 56298228 23551464 32746764 2077821 1444450 633371 26411149 18538783 7872366 578252 578252 43463028 CMDI 607045 Deferred Debt Acquisition Cost 712948 Funds Held by Trustee 8114537 Limited Use Assets 1316026 10750556 Current portion of long term debt 2281569 2281569 1 1 1 X 275.000000000000 0 1 1 1 0 1 1 1455907 1455907 0.01630 14578512 8785301 5793211 0.06470 16034419 8785301 7249118 0.08100 131071 131071 0.00150 622225 622225 0.00690 2526 2526 0.00000 755822 755822 0.00840 16790241 8785301 8004940 0.08940 26622 26622 0.00030 26622 26622 0.00030 1 4179968 83599 14035021 16676830 -2641809 X 1 0 1 1 Fairview Red Wing Health Services

701 Fairview Blvd Red Wing MN 55066

X X X Fairview Red Wing Health Services 1 1 X X X X X X X X X 11 1 0 0 1 1 1 275.000000000000 1 275.000000000000 0 0 0 1 0 1 0 1 Part I, Line 3c: Patients that are eligible for the Fairview Community Care Program or other Charity Care Plans may receive a reduction on amounts owed or up to 100% of total charges. Fairview informs patients about the Community Care Program prior to delivery of services if feasible and as appropriate and during the billing process. Fairview's uninsured discount program gives uninsured patients with a household income below $125,000 an uninsured discount equivalent to Fairview's higest revenue private payer contracted rate for medically necessary services. Part I, Line 7: Fairview Red Wing Health Services uses the cost to charge ratio method for determining expenses. The Medicare cost reporting calculates services line by line where other expenses are calculated at the overall cost to charge ratio. One component of the costing method used is the Other Means tested government program. Minnesotas General Assistance Medical Care program (GAMC) meets this criteria. GAMC is a state funded program for low income adults, ages 21-64, who have no dependent children living with them and who do not qualify for federally funded health care programs. Eligible recipients must also meet income and asset tests. Part I, Line 7g: Fairview Red Wing Health Services provides inpatient units and ambulatory programs that serve low-income communities and home health programs. The following are areas of need which have been identified: Adolescent health based on assessment of diet, nutrition and exercise, as well as assets and risk behaviors such as substance use. Part I, L7 Col(f): The provision for bad debts is based on management's assessment of historical and expected net collections considering historical business and economic conditions, trends in healthcare coverage, and other collection indicators. Part II: Fairview Red Wing Health Services is involved in a limited number of activities which are classified by definition as community building activities. While the majority of community activity addresses direct health needs, the community building activities are valuable for building tangible and intangible community infrastructure housing, safety, leadership skills and more. Part III, Line 4: The provision for bad debts is based on management's assessment of historical and expected net collections considering historical business and economic conditions, trends in healthcare coverage, and other collection indicators. Fairview Red Wing Health Services uses the cost to charge ratio method for determining expenses. Part III, Line 8: Fairview Red Wing Health Services uses the cost to charge ratio method for determining expenses. The Medicare cost to charge ratio reporting is calculated service line by service line. Other expenses are calculated using the overall cost to charge ratio. Part III, Line 9b: After our patients have received services, it is the policy of Fairview Red Wing Health Services to bill patients and their applicable payors on a timely and accurate basis. During this billing and collection process, Fairview staff will be committed to providing quality customer service and timely follow up on all outstanding accounts. Billing: It is the goal of Fairview to bill all claims accurately and on a timely basis. Although dependent on information and communications from patients and payors, Fairview Red Wing Health Services will provide sufficient follow up service to ensure that patients receive accurate account and billing information and have the oportunity to make payment and/or apply for community care. The billing process will be assisted by the following guideline:1) For all insured patients, Fairview Red Wing Health Services will bill all third party payor information (as provided by or verified by the patient) on a timely basis.2) For all uninsured with Minnesota residency receiving hospital based services deemed medically necessary. Fairview Red Wing Health Services will apply an uninsured discount equal to the discount provider to our largest contracted non-government payor, any remaining balance will be billed to the patient in a timely manner.3) All billed patients have the opportunity to contact Fairview Red Wing Health Services regarding financial assistance for their accounts. Financial assistance may include Community Care, payment arrangements, medical assistance or other applicable programs.4) If a patient contacts Fairview Red Wing Health Services regarding Community Care the account will not be referred to a collection agency or attorney, once the application and required documentation is received (income verification etc). The account will then be processed based on the outcome of the Community Care determination.5) If a patient contacts Fairview Red Wing Health Services regarding Community Care after their account has been referred to a collection agency or attorney, Fairview Red Wing Health Services will send a application to the patient, provided the account meets the Community Care requirements. If the completed application with required documents (income verification, etc.) is submitted, all collection action will be suspended until the patient is notified of Fairview Red Wing Health Service's determination. Fairview Red Wing Health Services Part V, Section B, Line 9: In support of our values and mission and in compliance with the Minnesota Attorney General Agreement signed by Fairview, Fairview Red Wing Health Services is providing uninsured patients with a household income below $125,000 an uninsured discount on billed charges equivalent to Fairview Red Wing Health Services' highest revenue private payer contracted rate for medically necessary services. Fairview Red Wing Health Services Part V, Section B, Line 16e: It is the goal of Fairview Red Wing Health Services to bill all claims accurately and on a timely basis. Although dependent on information and communication from patients and payors, Fairview Red Wing Health Services will provide sufficient follow up service to ensure that patients receive accurate account and billing information and have the opportunity to make payment and or apply for Community Care. Fairview Red Wing Health Services Part V, Section B, Line 21: Patients who do not comply with the Community Care application process may be denied Community Care. Patients who have insurance and payment has not been received from the insurance company will be denied Community Care if the applicant fails to cooperate with claims filing or collecting from potential third party resources. Other exclusions include services from non-Fairview providers, other Fairview providers not covered by the Charity Care policy and expenses related to transportation or personal living expenses. Non-US Citizens are not eligible for Community Care unless they are an undocumented alien and have established residence in the United States. Out-of-state residents are not eligible for 100 percent Community Care Discount. Part VI, Line 2: Community health assessments are conducted by Fairview Health System's corporate community health department staff every year on a rolling three year cycle for the primary service areas within Fairview Red Wing Health Services. Year 1: Basic Demographic Assessments Year 2: Adolescent Assessments Year 3: Site or Issue Specific Assessments (e.g. analysis of charity care patients). Staff start with existing community documents to build a baseline of information. Information may include patient data, existing recent social and cultural reports, education and business reports, new demographic information about income, housing, education and more. Next, staff conduct key interviews with community leaders from diverse sectors social services, philanthrophy, government, health, education, business, minority groups, faith groups. Interview allow assumptions to be validated and new information to be gathered. In addition site community health staff work with local public health departments and other community groups as part of their supplemental assessment of community need and/or to utilize the findings from their groups in understanding their communities. Beyond the formal needs assessments, Fairview leadership is engaged in their respective communities. Involvement includes participation on community boards, foundations, schools and more. Fairview also seeks community involvement through, community leaders serving on hospital boards and committees. Information gleaned through these connections are equally important as the formal needs assessments. Often these connections can identify emerging issues. Part VI, Line 3: Fairview makes informaton about their charity care programs available on the Website (www.fairview.org), at the time of registration for services and through written materials in lobbies and waiting rooms. For patients identified as self-pay (whether that occurs before services are delivered or during the billing cycle), Fairview Red Wing Health Services utilizes a standard process to help patients learn about and access assistance from government programs or Fairview's charity care program.For uninsured patients seen in a Fairview hospital, Fairview partners with an external vendor who meets with self-pay patients to help them determine eligibility for government programs of Fairview's charity care program. The vendor will also help patients complete necessary paperwork to assess these resources.Staff in Fairview's business office have a self-pay team, which directs patients to the appropriate resources. There is also a community care coordinator who helps get patients connected to additional resources for which they may qualify. Part VI, Line 4: Fairview Red Wing Medical Center has a primary service area of 47,000 individuals who reside in Goodhue County in Minnesota and Pierce County in Wisconsin. This rural, agricultural community is relatively stable by population, ethnicity and language.Red Wing is located in Goodhue County. Fairview Red Wing Medical Center is the only hospital in the community. Fairview Red Wing provides a full continuum of services, from primary care services at the clinic to home care services to long-term care. Part VI, Line 5: Fairview Red Wing Health Services is governed by an unpaid board of directors. The majority of the directors are community members who represent the various service areas and entities within the system. Part VI, Line 6: As a nonprofit health system, Fairview Red Wing Health Services reinvests any excess revenues into the core operations of the organization. The Fairview corporate community health department supports the local effort by sharing best practices, finding efficiencies among hospital community health leaders as appropriate, coordinating the formal community needs assessments and more. Reports Filed With States Part VI, Line 7 MN 1 X X X X X 0 1 0 0 0 0 0 0 0 Jeffrey Ketcham M D 622425 0 0 0 0 0 17150 0 14349 0 653924 0 0 0 Jack Alexander M D 252549 0 0 0 0 0 17150 0 14442 0 284141 0 0 0 Amy DeJong M D 219699 0 0 0 0 0 15963 0 14442 0 250104 0 0 0 Paula Phillippe 0 375027 0 67103 0 36158 0 0 0 72123 0 550411 0 0 John Doherty 0 323460 0 71300 0 0 0 19116 0 32841 0 446717 0 0 Scott R Wordelman 0 284284 0 91586 0 2517 0 5886 0 16611 0 400884 0 9317 Michael Larson 208795 0 0 0 11915 0 16051 0 14000 0 250761 0 0 0 Nancy Dimunation 160379 0 0 0 0 0 11296 0 11937 0 183612 0 0 0 Matthew A Eich M D 622666 0 0 0 0 0 17150 0 13117 0 652933 0 0 0 Everett M Hughes 586449 0 0 0 19819 0 17150 0 14349 0 637767 0 0 0 Michael R Johnson 501501 0 0 0 17173 0 0 0 14349 0 533023 0 0 0 Christopher McDevitt 418072 0 0 0 0 0 17150 0 14349 0 449571 0 0 0 Part I, Line 4b Those participating in a supplemental non-qualified retirement plan: Scott Wordelman $7208. City of Minneapolis 416005375 60374VCH4 2008-11-12 49815000 Refunded 2005B refunding 2000A Issue for new medical center. 0 0 0 City of Minneapolis 416005375 60374VCH4 2008-10-29 9066000 Hospital surgery expansion 0 0 0 49815000 720000 49095000 0 0 0 0 9066000 79000 8987000 2009 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0 0 0 0 0 1 0 0 0 1 Form 990, Part VI, Section A, line 6 Fairview Health Services is the sole member of Fairview Red Wing health Services. Form 990, Part VI, Section A, line 7a Fairview Health Services has reserve powers. Form 990, Part VI, Section A, line 7b Governance decisions are subject Fairview Health Services (FHS) reserve powers. Board membership is as follows: CEO is ex-officio-voting, 2 members appointed by FHS, employed physicians of Fairview Red Wing Health Services elect two employed physicians and 6 community members are nominated by Fairview Red Wing Health Services board nominating committee, approved by the Red Wing Board and appointments are ratified by Christian Health Services, a group of Red Wing churches. Fairview Red Wing Health Services CMO and a University of Minnesota Physicians representative are exofficios without vote. Form 990, Part VI, Section B, line 11 The Tax Department conducts a detailed review of the completed return. The return is also review by the VP and Chief Financial Officer. The Form 990 is presented to the Finance area for review of content. The Form 990 is subsequently presented to the Board of Directors. Upon approval from the Board of Directors, the Form 990 is filed. Form 990, Part VI, Section B, line 12c Managers, directors and senior management of Fairview Red Wing Health Services are required to annually complete Fairview's Duty of Loyalty and Conflict of Interest Statement in compliance with Fairview's Conflict of Interest policy. Disclosures are reviewed by the compliance department. Conflicts of interests by Board members are brought to the Audit and Compliance Committee of the Board, along with additional detailed information, for specific review. In addition, the Compliance Officer compiles a schedule showing reported conflicts of interest by managers, directors and senior management which is also presented to the Audit and Compliance Committe of the Board for review and discussion. Any problematic issues arising from these disclosures are discussed and resolved by the committee. Board members and management employees are expected to update their conficts, as necessary, during the year. Form 990, Part VI, Section B, line 15 The determination of executive compensation of the organization is processed by the Human Resources Executive Committee and includes a review of comparablility data, review by independent experts and contemporaneous substantiation of the deliberation and decision process. Form 990, Part VI, Section C, line 19 Fairview Red Wing Health Services makes its governing documents, conflict of interest policy, and financial statements available to the public upon request and inspection of the documents is available at the corporate finance department. Fairview Regional Community Services PO Box 95 - 701 FAIRVIEW BLVD Red Wing MN 55066 411539756 Home healthcare services MN 501c(3) 7 0 Fairview Seminary Home PO Box 95 - 701 FAIRVIEW BLVD Red Wing MN 55066 411263419 Resident care and housing MN 501c(3) 9 0 Fairview Seminary Plaza PO Box 95 - 701 FAIRVIEW BLVD Red Wing MN 55066 411532554 Elderly housing MN 501c(3) 9 0 Fairview Health Services 2450 Riverside Avenue Minneapolis MN 55454 410991680 Hospital patient services MN 501c(3) 3 0 Fairview Foundation 2450 Riverside Avenue Minneapolis MN 55454 411573810 Fundraising to support Fairviews mission MN 501c(3) 7 0 Fairview Home Care and Hospice 2450 26th Ave S Minneapolis MN 55406 411434246 Home Health Care MN 501c(3) 9 0 RMC Properties 2450 Riverside Avenue Minneapolis MN 55454 411482417 Land Lease Hold MN 501c(3) 9 0 Fairview Physician Associates Network 3400 West 66th Street Minneapolis MN 55435 411753325 Clinical Integration MN 501c(3) 9 0 Range Regional Health Services 750 East 34th Street Hibbing MN 55746 411293970 Hospital patient services MN 501c(3) 3 0 Ebenezer Social Ministries 2722 Park Avenue South Minneapolis MN 55407 411883845 Nursing Home Management MN 501c(3) 9 0 Fairview Auxiliary 6401 France Avenue South Minneapolis MN 55435 411414831 Support hospital services MN 501c(3) 13 0 Fairview Clinics 2450 Riverside Avenue Minneapolis MN 55454 411761760 Physician Services MN N/A C Fairview Physician and Clinic Services 2450 Riverside Avenue Minneapolis MN 55454 411544996 Physician Services MN N/A C Ridges Development Co & Subsidiary 2450 Riverside Avenue Minneapolis MN 55454 411568579 Leasehold Management MN N/A C Fairview Subsidiary III (Express Care) 2450 Riverside Avenue Minneapolis MN 55454 205996177 Physician Services MN N/A C Behavioral Healthcare Providers 2450 Riverside Avenue Minneapolis MN 55454 411805759 Mental Health Practitioners MN N/A C Surgical Consultants 2450 Riverside Avenue Minneapolis MN 55454 410877307 Medical Services MN N/A C Minnesota Heart 2450 Riverside Avenue Minneapolis MN 55454 411598660 Medical Services MN N/A C 0 0 1 0 0 0 0 0 0 0 0 1 0 0 1 1 1 0 Fairview Health Services L 87677 Fairview Seminary Plaza O 82 Fairview Regional Community Services P 102 Fairview Red Wing Auxiliaryn Association C 24334 Fairview Health Services P 19386 Fairview Health Services Q 190833