2012-11-14T16:44:28-07:00 2011-12-31 990 2011-01-01 391028081 BELOIT HEALTH SYSTEM INC BELO 6083645011 1969 West Hart Road Beloit WI 53511 William Groeper 6083645281 2012-11-14 2011 2016-02-24 21:20:13Z Gregory K Britton 1969 West Hart Road Beloit WI 53511 188333798 0 X www.beloithealthsystem.org X 1965 WI The mission of Beloit Health System is to be the leader in regional health and wellness services that delivers high quality, value, and satisfaction to our patients and communities we serve. 13 5 1649 425 301209 0 0 0 177222838 182496310 817049 1207498 4496063 4629990 182535950 188333798 0 0 0 0 107711789 110980222 0 0 0 67559452 68378983 175271241 179359205 7264709 8974593 191593671 203439891 113912312 127310310 77681359 76129581 Beloit Health System provides quality medical health care regardless of race, creed, sex, national origin, disability, age or ability to pay. During 2011, the System's Hospital served over 4,400 inpatients and provided more than 726,000 outpatient services, the NorthPointe facility provided more than 74,000 outpatient services and the Clinics had over 220,000 encounters. The System is equipped to serve the greater Beloit areas entire spectrum of health needs and strives to continue the long-standing tradition of providing excellent general acute care and to better serve the greater Beloit area. 0 0 43504517 56591202 Inpatient Revenue: Total admissions of 4,404 with an average daily census of 47. This was a slight 1% decrease from 2010 mainly due to continued economic uncertainty as well as the fact that more and more services are transitioning to an outpatient type setting. Total patient days were 17,139 101510536 0 125603899 Outpatient Revenue: Beloit Memorial Hospital successfully integrated with the Beloit Clinic in 2010 to create the Beloit Health System. Outpatient revenue has shown continued growth with the addition of physicians in certain specialties. Total Hospital and NorthPointe outpatient procedures for 2011 were 800,539. Total Clinic encouters were 220,275. 0 0 0 145015053 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 1 0 0 0 0 1 0 0 1 1649 1 1 1 0 0 0 0 0 X 13 5 1 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 0 0 X X Beloit Health System Inc 6083645102 1969 West Hart Road Beloit WI 53511 G Curtis Lansbery 0 X X 0 0 0 Bonnie D Wetter 0 X X 0 0 0 Steven M Eldred 0 X X 0 0 0 Russel Albert MD 40 X X 376369 0 15925 Gregory K Britton 40 X X 567782 0 540273 Suzanne Anderson 0 X 0 0 0 Leo Egbujiobi MD 40 X 1041992 0 15925 James B Fisher 0 X 0 0 0 Mark Gliebe 0 X 0 0 0 James L Packard 0 X 0 0 0 Tejesh Patel MD 40 X 344073 0 15925 Mario Rojas MD 40 X 567843 0 15925 Bill Sullivan 40 X X 311973 0 15925 Timothy M McKevett 40 X 295738 0 91049 William Groeper 40 X 250585 0 14557 Leland From MD 40 X 256649 0 20206 Doris Mulder 40 X 217442 0 80390 Kristinn Armann 40 X 154724 0 17028 Paul Segal MD 40 X 793449 0 15925 Emmy Ho MD 40 X 734980 0 15925 Tsu-Hon Wang MD 40 X 709877 0 15925 Glenn Tan MD 40 X 663239 0 15925 John Johanson MD 40 X 648437 0 15925 7935152 0 922753 93 0 1 0 North American Mechanical 330 E Delavan Drive Janesville WI 53546 Construction Contractors 902796 Power Wellness Management LLC 2055 W Army Trail Road Suite 124 Addison IL 60101 Wellness Operations Contractor 998013 Clear Choice Transcription LLC PO Box 643455 Cincinnati OH 452643455 Transcription Services 738369 Southern WI Emergency Association 1664 N Randall Janesville WI 53545 Trauma Physicians 502676 Guenther Electric Inc 220 Liberty Avenue Beloit WI 53511 Electrical Contractors 447590 15 0 Outpatient Service Revenue 622000 125603899 125603899 0 0 Inpatient Service Revenue 622000 56591202 56591202 0 0 Third Party Adminstration 524292 301209 0 301209 0 0 0 0 0 182496310 1207498 0 0 1207498 0 0 0 0 0 0 0 0 292881 0 0 0 292881 0 292881 0 0 292881 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Wellness Center & Spa Revenue 622000 2937435 0 0 2937435 Cafeteria & Snack Shop Revenue 622000 608487 0 0 608487 Physician Billing 622000 138350 0 0 138350 652837 0 0 652837 4337109 188333798 182195101 301209 5837488 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 79072248 65026670 14045578 4321583 3543698 777885 22514245 18461681 4052564 5072146 4159160 912986 0 12174 0 12174 80100 0 80100 0 0 0 0 0 0 0 0 0 5403585 4392625 1010960 1464452 1200851 263601 25368930 22697758 2671172 1420516 0 1420516 0 0 0 6012019 4929856 1082163 507826 252056 255770 27604 5810 21794 3653150 2995583 657567 9699138 7953293 1745845 1302670 1302670 Equipment Rental & Maintenance 5637628 2484778 3152850 WI Provider Tax 4602457 4602457 0 Other Purchased Services 2618866 866189 1752677 Professional Memberships 220831 139918 80913 347037 347037 179359205 145015053 34344152 0 9035 9035 15808573 25022490 25058445 24403307 812752 493011 2432468 2219638 2113888 3702970 186138978 86087285 101717940 100051693 32884646 36711033 3580000 3510000 7175924 7316714 191593671 203439891 19770232 22657559 3245545 3895631 70365000 70080000 2387255 2119240 18144280 28557880 113912312 127310310 X 77681359 76129581 0 0 0 0 77681359 76129581 191593671 203439891 X 8974593 -10526371 X 0 1 1 X 0 X 1700000 5865455 7565455 0 105217733 34125506 71092227 0 5920816 2832115 3088701 0 67376727 49129664 18247063 0 58247 0 58247 100051693 0 Pension Liability 16754275 Interest Rate Swap Agreements 11731493 Capitalized Leases 72112 28557880 188333798 179359205 8974593 0 0 0 0 -419965 -419965 8554628 188333798 0 0 0 0 0 188333798 0 0 0 188333798 179359205 0 0 0 0 0 179359205 0 0 0 179359205 SchD_P10_S00_L02 Schedule D, Part X, Line 2 The Health System is a nonprofit corporation as described in Section 501(c)(3) of the Internal Revenue Code (the "Code") and is exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. The System is also exempt from state income taxes on related income. In order to account for any uncertain tax positions, The Corporation determines whether it is more likely than not that a tax position will be sustained upon examination on the technical merits of the positon, assuming the taxing authority has full knowledge of all information. If the tax position does not meet the more likely than not recognition threshold, the benefit of that position is not recognized in the financial statements. The Corporation recorded no assest or liabilities related to uncertain tax positions in 2011 and 2010. Tax returns for the years ended 2008 and beyond remain subject to examination by the Internal Revenue Service. SchD_P11_S00_L08 Schedule D, Part XI, Line 8 Total is derived from the change in market value on Pension Restoration Asset for $(113,686) plus the change in market value of the Interest Rate Swap Agreements $(306,279). All nonoperating items are not included on Form 990 Statement of revenue and Functional Expenses. Total other is $(419,965). 1 1 1 X 1 X 1 1 1 0 1 1 11303128 0.063 32761305 19297376 13463929 0.075 0 0 32761305 19297376 24767057 0.138 17120 185926 9062 176864 0.001 192 196641 0 196641 0.001 16536 88251 0 88251 0 0 33848 470818 9062 461756 0.002 0 33848 33232123 19306438 25228813 0.140 1 3398679 0 27900789 121417412 -93516623 X 1 1 1 1 Beloit Memorial Hospital

1969 West Hart Road Beloit WI 53511

X X X X Beloit Memorial Hospital 1 10 Beloit Clinic

1905 E Huebbe Parkway Beloit WI 53511

Ourpatient Physician Clinic Northpointe Health and Wellness

5605 E Rockton Road Roscoe IL 61073

Other Outpatient Physcian Clinic and Diagnostic Center Beloit At-Home Healthcare

1904 E Huebbe Parkway Beloit WI 53511

At Home Healthcare Practice Riverside Terrace

3055 S Riverside Drive Beloit WI 53511

Assisted Living Center Northpointe Terrace

5601 Rockton Road Roscoe IL 61073

Assisted Living Center Occupational Health Sports and Family Medicine

1650 Lee Lane Beloit WI 53511

Outpatient Physician Clinic West Side Clinic

1735 Madison Ave Beloit WI 53511

Outpatient Physician Clinic Clinton Clinic

307 Ogden Ave Clinton WI 53525

Outpatient Physician Clinic Darien Clinic

300 N Walworth Darien WI 53114

Ourpatient Physician Clinic Janesville Clinic

1321 Creston Park Janesville WI 53545

Outpatient Physician Clinic South Beloit Facility

1655 Blackhawk Blvd South Beloit IL 61080

Unoccupied SchH_P01_S00_L06a Schedule H, Part I, Line 6a Each year the Beloit Health System prepares a community benefit report using the guidelines of the Wisconsin Hospital Association (WHA). It is then submitted to WHA foir data tracking and reporting purposes. SchH_P01_S00_L07 Schedule H, Part I, Line 7 Costing methodology used was the Ratio of Patient Care Cost to Charges with guidance from the IRS worksheets in the instructions. SchH_P01_S00_L072f Schedule H, Part I, Line 7, Column f Not applicable SchH_P01_S00_L07g Schedule H, Part I, Line 7g Not applicable SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 Patient accounts receivable are recorded net of contractual adjustments and allowance for doubtful accounts which reflects management's best estimate of the amounts that won't be collected. Management provides for contractual adjustments under terms of third-party reimbursement agreements through a reduction of gross revenue and a credit to patient accounts receivable. In evaluating the collectibility of patient accounts receivable,the System analyzes historical loss experience on revenue from non-governmental payors. The loss experience rate is applied to current year non-governmental revenue as a basis for the allowance for doubtful accounts. The System also considers receivables from non-governmental payors aged over 151 days. Based on these factors, the System eliminates the appropriate allowance for doubtful accounts and provision for bad debts. The difference between the standard rates (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. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 Costing methodology used for Medicare allowable costs came directly off the 2011 Medicare Cost Report on Worksheet B per the IRS instructions. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b The Health System's collection policy states that patient accounts that have aged 100 days are to be reviewed for possible collection and pre-collection activity by a Credit Consultant. For accounts over $100, if it has been determined that no payment is forthcoming from a third-party payor and the patient had made no attempts to satisfy the balance of the account, a pre-collection letter shall be sent to the patient by a collection agency. If satisfactory payment arrangements are not made within 15 days of the letter, the account status shall be changed to bad debt. For account balances under $100, if it has been determined that no payment is forthcoming from a third-party payor and the patient has made no attempts to satisfy the balance of the account, the account status shall be changed to bad debt. No pre-collection letter will be sent. All accounts in a Bad Debt status are transferred to a collection agency on the 15th and 30th of each month. Pre-collection accounts are transferred on the same dates. Accounts for services rendered for Hospital physicians or members of the Board shall not be transferred to bad debt or pre-collection without the approval of the Patient Accounts Advisor. The Health System will not force the sale or foreclosure of a patient's primary residence to pay an outstanding medical bill. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 There are primarily three ways the Health System assesses health care needs of the community. 1) A marketing group is used and their service is to measure through phone interviews, etc. what the needed medical services are, how our services are perceived, and are there any disconnects between these community needs, our actual services, and the community perception. 2) The Health System also looks at out migration data. Often limited to CMS data, this is what services (by CPT codes) were billed for residents of a particular zip code and where they go to get that service. If the volume of people going to our facilities is large, the Health System will review the costs, etc. of providing that service within the Health System. 3) The Health Systems corporate culture strongly supports due diligence for any request we receive from patients, family members, and their agents. Another way the Health System attempts to assess the health needs of the community is through Rock County Health Needs Assessment Task Force which has been established for this purpose and meets on a monthly basis. Beloit Health System has two representatives on the task force as well as representation from all other area hospitals and major health providers within the County. Primary purpose of this task force is to compile county-wide data as well as Beloit specific data on major health parameters to address through a perception of needs survey. Action plans are then developed to meet gaps between services provided and the needs of the community. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 Information about the Health System's charity care benefits are available on the Health System's website as well as in all patient rooms. In addition, admissions staff are trained to offer financial assistance applications to all uninsured patients who inquire at the time of registration. Finally, every patient billing statement includes contact information for the System's charity care benefits. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 Beloit, Wisconsin is a community of approximately 38,000 residents and located just north of the Wisonsin-Illinois border. One of the most ethnically diverse communities in the Midwest, the population is 67% Caucasian, 15% African American, 9% Hispanic/Latino, and 1% Asian American, with another 8% from other ethnic backgrounds. The Health System monitors market share based on service areas identified through the use of zip codes. The primary and secondary service area represent a market population of approximately 250,000 people. 93% of the System's patients are from Beloit, Janesville, Clinton (all Rock County, WI) South Beloit and Rockton (in Winnebago County, IL). The remaining 7% are from other Wisconsin and Illinois communities. Median household income for Rock County, WI is $50,373 and for Winnebago County, IL is $47,859. Unemployment is the area remains high for 2011 but much better than in 2010. Rock County, WI had an unemployment rate of 9.2% in 2011 compared to 11.4% in 2010. Winnebago County, IL had an unemployment rate of 12.0% in 2011 compared to 16.1% in 2010. Sources of Beloit Health System's gross patient revenue are 45.6% Medicare, 16.2% Medicaid, 5.1% Self Pays, and 33.1% Other Insurances. SchH_P06_S00_L05 Schedule H, Part VI, Line 5 The Health System actively provided or participated in the following community based activities and programs. 1) General health education services such as health fairs, cancer education, health heart education, family planning, and mental health education. 2) Provided health information on the System's website and through health-related publications distributed at no charge. 3) Support groups such as AIDS/HIV, diabetes, substance abuse, and weight management. 4) Self help and wellness programs such as nutrition and weight management and sports injury prevention. 5) Blood pressure screenings, cholesterol testing, and hearing testing. 6) Crisis intervention counseling. 7) Guidance, referral, and enrollment assistance for public medical programs and other family support assistance. 8) Provided discounted or free medical supplies and equipment to those unable to pay. 9) Delivered hot in-home meals. 10) Provided emergency bus tokens for the indigent to access health care services. 11) Promoted participation in blood drives by employees. 12) Contributed to the education of student nurses and other health care professionals. Also, the Beloit Area Community Health Center has approached the Health System as to provide specialty physician care to indigent patients. This is a project above and beyond the Health System's current charity care process in that physicians are volunteering their time. SchH_P06_S00_L06 Schedule H, Part VI, Line 6 Not applicable SchH_P06_S00_L07 Schedule H, Part VI, Line 7 Wisconsin X X X X 0 1 0 0 0 0 0 0 0 Gregory K Britton 414182 0 153600 0 0 0 540273 0 0 0 1108055 0 986485 0 Leo Egbujiobi MD 1041992 0 0 0 0 0 15925 0 0 0 1057917 0 993850 0 Paul Segal MD 793449 0 0 0 0 0 15925 0 0 0 809374 0 804966 0 Emmy Ho MD 734980 0 0 0 0 0 15925 0 0 0 750905 0 862513 0 Tsu-Hon Wang MD 709877 0 0 0 0 0 15925 0 0 0 725802 0 724600 0 Glenn Tan MD 663239 0 0 0 0 0 15925 0 0 0 679164 0 572015 0 John Johanson MD 648437 0 0 0 0 0 15925 0 0 0 664362 0 0 0 Mario Rojas MD 567843 0 0 0 0 0 15925 0 0 0 583768 0 527457 0 Russel Albert MD 376370 0 0 0 0 0 15925 0 0 0 392295 0 377416 0 Timothy M McKevett 248737 0 47004 0 0 0 91049 0 0 0 386790 0 367069 0 Tejesh Patel MD 344073 0 0 0 0 0 15925 0 0 0 359998 0 370621 0 Bill Sullivan 265173 0 46800 0 0 0 15925 0 0 0 327898 0 267271 0 Doris Mulder 182350 0 35092 0 0 0 80390 0 0 0 297832 0 304912 0 Leland From MD 244049 0 12600 0 0 0 20206 0 0 0 276855 0 0 William Groeper 212785 0 37800 0 0 0 14557 0 0 0 265142 0 222988 0 Kristinn Armann 131724 0 23000 0 0 0 20206 0 0 0 174930 0 185100 0 SchJ_P01_S00_L04 Schedule J, Part I, Line 4 457(f) Plan Participants: Gregory K. Britton and Doris Mulder - no payments received to date. Illinois Finance Authority 2010-10-21 37895000 Proceeds along with existing balances in the 2006A funds were used to refund the Series 2006A Bonds 0 0 0 Wisconsin Health and Educational Facilities Authority 97710BYF3 2010-10-21 32470000 Refund Series 2006B and refinance loans used for the acquisition of Beloit Clinic and ER renovations 0 0 0 285000 0 37895000 0 0 0 255032 0 0 0 0 0 2007 1 0 1 1 0 0 32470000 2764200 0 0 510859 0 0 0 0 14450 2010 1 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 1 1 Piper Jaffray 25.5 0 0 0 0 0 0 0 0 0 0 0 First National Bank & Trust Co An entity with System Board Conections 0 Bank accounts and normal business 0 Marshall & Ilsley Trust Co An entity with a System Board connection 0 Trustee fior Hospital Pension Plans 0 Regal Beloit Corp An entity with a System board connection 0 Medical clains paid to Health System 0 SchL_P04_S00_L00 Schedule L, Part IV An amount of $0 was entered in column c due to the inability to quantify an accurate total amount for the year. However, all transaction are considered to be in the normal course of business. F990_P06_S0A_L02 Form 990, Part VI, Section A, Line 2 There are several business relationships on the Board as there are two board members currently key employees of local banks: First National Bank and Trust Company and Marshall and Ilsley Trust Company. All relationships are considered normal banking relationships and all transactions are within the normal course of business. F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b Form 990 is prepared by an employee of the Health System's accounting staff and is reviewed by the VP of Financial Services, where it is signed and filed. After filing the return, the VP will present Form 990 to the Board. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c It is the policy of the Health System that any leadership staff who believes he or she may be acting in contrary to the conflict of interest policy to promptly disclose the conflict to his or her supervisor. Employees should immediately report all known, observed or potential conflict of interests to their immediate supervisour or Human Resources. It is the responsiblilty of the President to enforce and interpret this policy on all related matters. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 The Hospital Board of Directors has established a CEO Evaluation Committee to evaluate the CEO's performance based on criteria and links performance evaluation to compensation. This committee meets at least three times per year to establish and review measurable goals. Outside directors establish performance criteria, compensation, and benefit programs for the CEO. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 Beloit Health System makes its financial statements available to the public via summary in the annual financial report which is posted on the Health System's website (www.beloithealthsystem.org). Also available on the website is the Board of Trustees Principle Based Governance Policy. It has been adopted by the Trustees and applies to all aspects of the governance to create a consistent, effective, and continously improving governance system. The principles are divided into three major categories: 1) Board Independence and Leadership 2) Board Processes and Evaluation and 3) Board structure. F990_P11_S00_L05 Form 990, Part XI, Line 5 Change in pension obligation: $(4,901,997). Net assets released from restrictions and contributions for capital improvements: $520,193. Change in net unrealized gains and losses on investments other than trading securities: $(885,303). Foundation receivable write-down: ($77,956). Change in fair value of effective portion Interest rate swap agreements: $(4,761,343). Change in market valuation of Swap Agreements: $(306,279). Change in market valuation of Retirement Supplement Agreement: $(113,686). Beloit Health System Foundation Inc 1969 West Hart Road Beloit WI 53511 391477854 Support Beloit Health System WI 501(c)(3) 3 N/A Beloit Memorial Hospital Auxiliary Inc 1969 West Hart Road Beloit WI 53511 390928583 Support Beloit Health System WI 501(c)(3) 3 N/A 0 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 Beloit Health System Foundation Inc c 530765 Actual cash received fron Beloit Health System Foundation Beloit Health System Foundation Inc o 77956 Actual expenses incurred by Beloit Health System Foundation and paid by Beloit Health System. Beloit Health System Foundation Inc m 0 Beloit Health System Foundation uses office space at Beloit Health System. No amount of consideration is received Beloit Memorial Hospital Auxiliary Inc m 0 Beloit Memorial Hospital Auxiliary uses office space of Beloit Health System. No amount of consideration is received