2011-02-15T14:00:43-06:00 2010-03-31 PLANTE & MORAN PLLC 600 E FRONT STREET SUITE 300 TRAVERSE CITY MI 49686 990 2009-04-01 381459366 CHARLEVOIX AREA HOSPITAL CHAR 2315474024 14700 LAKESHORE DRIVE CHARLEVOIX MI 49720 William Jackson 2315474024 2011-02-15 1 2319477800 2009 2016-02-24 21:20:13Z WILLIAM JACKSON 14700 LAKESHORE DRIVE CHARLEVOIX MI 49720 36575353 0 X WWW.CAH.ORG X 1919 MI PROVIDE HEALTHCARE TO THE RESIDENTS OF CHARLEVOIX AND NORTHERN ANTRIM COUNTIES. 14 12 368 67 198166 28706 528129 231547 31821167 31448335 -41947 2191088 144341 116985 32451690 33987955 142700 14129 0 18775188 19208506 0 43704 14093647 13562763 33011535 32785398 -559845 1202557 26162325 27657672 9993479 9659203 16168846 17998469 DEPEND ON US FOR EXCELLENT HEALTH CARE 0 0 6178040 4081668 PHYSICIAN OFFICES 4857000 9401924 OPERATING ROOM SERVICES - SURGERIES: 2,153 3599577 2059861 ROUTINE INPATIENT - DAYS OF CARE: 2,860 12326691 14129 15692360 OUTPATIENT CARE, DIAGNOSTIC AND LABORATORY SERVICES, EMERGENCY ROOM SERVICES, AND OTHER GENERAL HEALTHCARE SERVICES 12326691 14129 15692360 26961308 1 1 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 44 0 1 368 1 1 1 0 0 0 0 0 0 0 0 14 12 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 0 0 X TABITHA RUDOLPH 2315478508 14700 Lake Shore Drive Charlevoix MI 49720 STEVE HUFFORD OD 1.00 X X 0 0 0 SCOTT BEATTY 1.00 X X 0 0 0 MARY JASON 1.00 X X 0 0 0 RICHARD FISH DDS 1.00 X 0 0 0 MARC LAME MD 1.00 X 0 0 0 REBECCA HANEY 1.00 X 0 0 0 HAROLD NORM PERKINS 1.00 X 0 0 0 STEVE WEBER 1.00 X 0 0 0 MARK GROENINK 1.00 X 0 0 0 CASSANDRA WILLIAMSON 1.00 X 0 0 0 WILLIAM JACKSON 40.00 X X 152359 0 23919 Geralyn Doskoch MD 1.00 X 118382 0 17331 Richard Krueger 1.00 X 0 0 0 John Kurtz 1.00 X 0 0 0 Chris Unbehaun 1.00 X 0 0 0 JOSEPH SCHODDE 40.00 X 108753 0 20267 JAMES JEAKLE MD 40.00 X 318961 0 21770 RODERIC TINNEY MD 40.00 X 198817 0 21178 Mary Ivey MD 40.00 X 352139 0 19786 William Mosher III MD 40.00 X 217362 0 11435 Nathan Boss MD 40.00 X 183799 0 18770 1650572 0 154456 21 0 1 0 Pine River Medical Associates 14734 Park Avenue Charlevoix MI 49720 ER Physician Coverage 1221058 Floyd & Todd Wright Builders Inc 216 Ray Street Boyne City MI 49712 Construction Contractors 625546 MICHIGAN NEUROLOGY ASSOCIATES 1500 WEST PARK DRIVE SUITE 300 WESTBOROUGH MA 01581 MOBile MRI Services 210000 QUEST DIAGNOSTICS 4444 GIDDINGS ROAD AUBURN HILLS MI 48326 LABORATORY SERVICES 175319 MUNSON SUPPORT SERVICES 1105 SIXTH STREET TRAVERSE CITY MI 49685 LAUNDRY SERVICES 107447 5 180711 47897 2939 9910 231547 Health Services 900099 25625497 25427331 198166 OTHER RELATED REVENUE 900099 5822838 5822838 31448335 88480 88480 136446 150802 -14356 -14356 -14356 4533804 5400 2404763 31833 2129041 -26433 2102608 2102608 CAFETERIA SALES 722210 131341 131341 131341 33987955 31235813 198166 2322429 14129 14129 453933 138771 315162 14888656 12951970 1899382 37304 358062 358062 2472848 2468370 4444 34 1035007 876916 155252 2839 19900 19900 83085 83085 4758 4758 131419 131419 91703 72628 19075 308700 255110 53180 410 2077734 1698304 376528 2902 366368 366368 sUPPLIES 3926841 3554303 372487 51 Professional services & 2540449 2146215 394072 162 Other Expenses 1122414 706672 415740 2 Utilities 730014 730014 Provision for Bad Debts 686745 686745 1472633 303099 1169534 32785398 26961308 5780386 43704 19461 38222 977832 2700727 70579 45429 2526082 2455563 14000 7000 430281 396747 672836 640179 427151 498002 42678364 26255982 17460191 16422382 2089015 2612066 1329011 1337969 145886 503386 26162325 27657672 2898125 2472189 6338951 5631016 756403 1172998 0 383000 9993479 9659203 X 15291057 16970320 877789 1028149 16168846 17998469 26162325 27657672 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 8122 8122 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: Portion of Annual dues to Michigan Health & Hospital Association, North Central Council, and American Hospital Association that are used toward lobbying activities. 898861 898861 28674239 15426529 13247710 13094311 10829453 2264858 10953 10953 16422382 Cost report settlement payable 383000 383000 33987955 32785398 1202557 627066 627066 1829623 1 1 X 1 X 1 X 1 1 1 0 1 1 1078408 663657 414751 0.01290 3977533 2220370 1757163 0.05470 5055941 2884027 2171914 0.06760 75314 3835 71479 0.00220 75314 3835 71479 0.00220 5131255 2887862 2243393 0.06980 0 529205 172631 8284108 8204485 79623 X 1 1 Charlevoix Area Hospital

14700 Lake Shore Drive Charlevoix MI 49720

X X X Boyne Area Medical Center

223 N Park Boyne City MI 49712

Outpatient Physician Office Charlevoix Women's Health Care

14651 W Upright Street Charlevoix MI 49720

Outpatient Physician Office Boyne Rehabilitation Center

197 State Street Boyne City MI 49712

Rehabilitation Clinic jordan valley rehabilitation center

100 main st East Jordan MI 49727

rehabilitation Clinic Charlevoix Surgeons

14695 Park Ave Charlevoix MI 49720

outpatient Physician Office Physician Clinic of Charlevoix

14705 W Upright St Charlevoix MI 49720

outpatient Physician Office Part I, Line 3c: IN ADDITION TO USE OF THE FEDERAL POVERTY GUIDELINES, PATIENTS MUST ALSO SATISFY AN ASSET TEST LIMIT OF $62,000. FURTHERMORE, TOTAL MEDICAL DEBT WILL BE CONSIDERED ON A CASE BY CASE BASIS AS AN ADDITIONAL ELEMENT IN DETERMINING THE AMOUNT OF FINANCIAL ASSISTANCE. Part I, Line 7: A COST TO CHARGE RATIO, DERIVED FROM WORKSHEET 2, IS USED. Part I, Line 7f: THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 24E - BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE SCHEDULE H, PART I, COLUMN F PERCENTAGE EQUALS $686,745. Part III, Line 4: ACCOUNTS RECEIVABLE FINANCIAL STATEMENT FOOTNOTE:AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS ESTABLISHED ON AN AGGREGATE BASIS BY USING HISTORICAL WRITE-OFF RATE FACTORS APPLIED TO UNPAID ACCOUNTS BASED ON AGING. LOSS RATE FACTORS ARE BASED ON HISTORICAL LOSS EXPERIENCE AND ADJUSTED FOR ECONOMIC CONDITIONS AND OTHER TRENDS AFFECTING THE HOSPITAL'S ABILITY TO COLLECT OUTSTANDING AMOUNTS. UNCOLLECTIBLE AMOUNTS ARE WRITTEN OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE. AN ALLOWANCE FOR CONTRACTUAL ADJUSTMENTS AND INTERIM PAYMENT ADVANCES IS BASED ON EXPECTED PAYMENT RATES FROM PAYORS BASED ON CURRENT REIMBURSEMENT METHODOLOGIES. THIS AMOUNT ALSO INCLUDES AMOUNTS RECEIVED AS INTERIM PAYMENTS AGAINST UNPAID CLAIMS BY CERTAIN PAYORS.THE RATIO OF PATIENT CARE COST TO CHARGES IS APPLIED TO BAD DEBT EXPENSE, NET OF RECOVERIES, TO ARRIVE AT THE ESTIMATED COST OF BAD DEBT $529,205.THE HOSPITAL PROVIDES CARE TO ALL INDIVIDIUALS REGARDLESS OF THEIR ABILITY TO PAY. WHILE THE HOSPITAL MAKES EVERY EFFORT TO IDENTIFY ALL CANDIDATES WHO WOULD QUALIFY UNDER ITS FINANCIAL ASSISTANCE POLICY, THERE ARE CIRCUMSTANCES UNDER WHICH THAT DETERMINATION CANNOT BE MADE. AS SUCH, IT IS OUR BELIEF THAT $172,631 OF BAD DEBT SHOULD BE INCLUDED AS COMMUNITY BENEFIT. BASED ON AN ANALYSIS OF SELF PAY ENCOUNTERS WHOSE GROSS CHARGES EXCEEDED $1,000 AND THEREFORE WERE AUTOMATICALLY SENT A FINANCIAL ASSISTANCE APPLICATION, IT WAS DETERMINED THAT APPROXIMATELY 54% QUALIFIED FOR FINANCIAL ASSISTANCE. THIS PERCENTAGE WAS THEN APPLIED TO TOTAL SELF PAY BAD DEBT AND THEN CONVERTED TO COST THROUGH APPLICATION OF THE RATIO OF PATIENT CARE COST TO CHARGES. Part III, Line 8: THE AMOUNTS REPORTED FOR MEDICARE ARE FROM THE MEDICARE COST REPORT, WHICH DO NOT SHOW A SHORTFALL. THIS IS BASED ON THE METHODOLOGY REQUIRED FOR COMPLETING THE MEDICARE COST REPORT. Part III, Line 9b: OUR HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS FROM PATIENTS DETERMINED TO QUALIFY FOR FINANCIAL ASSISTANCE. Part VI, Line 2: CHARLEVOIX AREA HOSPITAL HAS PARTICIPATED IN NEEDS ASSESSMENT SURVEYS CONSISTENTLY DURING THE PAST 10 YEARS, TYPICALLY IN COOPERATION WITH OTHER ORGANIZATIONS BUT AT TIMES SPECIFICALLY DRIVEN BY OUR HOSPITAL. IN ADDITION TO DATA PROCURED THROUGH THESE SURVEYS, OUR HOSPITAL HAS ALSO USED MICHIGAN DEPARTMENT OF COMMUNITY HEALTH - HEALTH DATA, STATE OF MICHIGAN CENSUS DATA, AND DATA FROM THE ECONOMIC DEVELOPMENT COUNCIL TO ASSESS THE ONGOING HEALTHCARE NEEDS OF OUR COMMUNITY. THE SURVEYS HAVE RESULTED IN MANY JOINT EFFORTS TO ADDRESS OUR COMMUNITY'S HEALTH CARE NEEDS (FLU CLINICS IN COOPERATION WITH LOCAL MDCH, GRANT PROCUREMENT FOR PACS AND DIGITAL MAMMOGRAPHY, AND FITKIDS). ADDITIONALLY, THE HOSPITAL HAS SOLELY SPONSORED WELLNESS WEDNESDAY'S, FREE MAMMOGRAPHY, AND SPORTS PHYSICALS FOR STUDENT ATHLETES. Part VI, Line 3: INFORMATION REGARDING THE AVAILABILITY OF FINANCIAL ASSISTANCE IS POSTED IN THE HOSPITAL'S ADMISSIONS AREAS. IF, DURING THE REGISTRATION PROCESS, IT BECOMES APPARENT THAT A PATIENT HAS NEED FOR POSSIBLE FINANCIAL OR DISCOUNTED ASSISTANCE, A REFERRAL IS MADE TO THE HOSPITAL'S FINANCIAL COUNSELOR OR SOCIAL WORKER. DURING THIS ASSESSMENT, ELIGIBILITY FOR ASSISTANCE UNDER EXISTING FEDERAL, STATE OR LOCAL GOVERNMENT PROGRAMS IS FIRST EXPLORED. SHOULD THE PATIENT FAIL TO QUALIFY FOR EXISTING PROGRAMS, THE HOSPITAL'S FINANCIAL ASSISTANCE APPLICATION IS MADE AVAILABLE. IN THE EVENT THE PATIENT'S NEED IS NOT IDENTIFIED DURING REGISTRATION, ADDITIONAL OPPORTUNITIES TO INQUIRE ABOUT FINANCIAL ASSISTANCE ARE MADE AVAILABLE. FOR EXAMPLE, THE PHONE NUMBER FOR INQUIRIES INTO FINANCIAL ASSISTANCE ARE PRINTED ON ANY STATEMENTS SENT TO THE PATIENT. FURTHERMORE, PATIENTS WHO DO NOT HAVE INSURANCE COVERAGE AND HAVE AN ENCOUNTER BALANCE THAT EXCEEDS $1,000 ARE AUTOMATICALLY SENT AN APPLICATION. Part VI, Line 4: CHARLEVOIX AREA HOSPITAL SERVES THE RESIDENTS OF CHARLEVOIX AND NORTHERN ANTRIM COUNTIES, AS WELL AS THE SEASONAL RESIDENTS THAT FLOOD THE AREA DURING THE SUMMER MONTHS. THIS SMALL, RURAL COMMUNITY IS HOME TO APPROXIMATELY 26,000 RESIDENTS, WITH A PER CAPITA INCOME OF APPROXIMATELY $40,000. BASED ON 2008 ESTIMATES, 11.2% OF THE POPULATION HAD INCOMES BELOW THE POVERTY LEVEL. SIMILARLY, MEDICAID RECIPIENTS ACCOUNTED FOR APPROXIMATELY 12% OF THE HOSPITAL'S GROSS PATIENT CHARGES. IN ADDITION, PATIENTS REFERRED FROM NEIGHBORING EAST JORDAN FAMILY HEALTH CENTER, A FEDERALLY QUALIFIED RURAL HEALTH CLINIC, WERE AMONG THOSE SERVED BY THE HOSPITAL. Part VI, Line 5: N/A - THE HOSPITAL DID NOT LIST ANY COMMUNITY BUILDING ACTIVITIES ON SCHEDULE H. Part VI, Line 6: THE BOARD OF DIRECTORS IS COMPRISED OF MEDICAL AND BUSINESS PROFESSIONALS, ALMOST ALL OF WHOM RESIDE IN THE HOSPITAL'S PRIMARY SERVICE AREA. THIS VOLUNTARY BOARD PROVIDES COUNTLESS HOURS OF SERVICE TO THE HOSPITAL IN THEIR OVERSIGHT ROLE. THEY ARE INVOLVED IN THE COMMUNITY NEEDS ASSESSMENT PROCESS, IN FUNDRAISING, AND IN GENERAL STEWARDSHIP. Part VI, Line 7: N/A - THE HOSPITAL IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. MI 1 Beaver Island Rural Health Center 37304 KINGS HIGHWAY BEAVER ISLAND MI 49782 383299988 501(C)(3) 7245 0 N/A N/A Telecommunication Grant East Jordan Family Health Center 601 BRIDGE STREET EAST JORDAN MI 49727 382150252 501(C)(3) 6884 0 N/A N/A Telecommunication Grant 2 0 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: REGARDING THE GRANT TO THE BEAVER ISLAND RURAL HEALTH CENTER, THE HOSPITAL PAID THE SUPPLIER OF THE TELEMEDICINE EQUIPMENT DIRECTLY, THEREBY ENSURING THE GRANT FUNDS RECEIVED FROM THE USDA WERE USED FOR THEIR INTENDED PURPOSE. X X 0 0 0 1 0 0 0 0 0 WILLIAM JACKSON 146443 0 0 0 5916 0 4639 0 19280 0 176278 0 0 0 JAMES JEAKLE MD 209180 0 96833 0 12948 0 6695 0 15075 0 340731 0 0 0 RODERIC TINNEY MD 145186 0 53249 0 382 0 4440 0 16738 0 219995 0 0 0 Mary Ivey MD 210211 0 141627 0 301 0 5751 0 14035 0 371925 0 0 0 William Mosher III MD 210620 0 4180 0 2562 0 6318 0 5117 0 228797 0 0 0 Nathan Boss MD 181428 0 2063 0 308 0 4811 0 13959 0 202569 0 0 0 Part I, Line 5 Employed physicians are paid an incentive bonus based on the gross value of professional service charges rendered to any and all patients, regardless of the patients' ability to pay. Net revenue collected on the PRO charges is not considered when calculating the incentive bonus. All incentive bonus agreements have overall caps on total compensation for which the physician is eligible in a twelve month time period. Mary Ivey MD RELOCATION Package X 21000 7000 0 0 1 7000 Form 990, Part VI, Section B, line 11 AN INFORMAL REVIEW OF THE 990 IS PERFORMED BY THE ADMINISTRATIVE TEAM AND BY MEMBERS OF THE EXECUTIVE COMMITTEE OF THE BOARD BEFORE THE RETURN IS FILED. Form 990, Part VI, Section B, line 12c ALL INDIVIDUALS SERVING ON THE BOARD ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST DISCLOSURE STATEMENT AND ARE PERIODICALLY REMINDED OF THEIR OBLIGATION TO REPORT ANY POTENTIAL CONFLICTS OF INTEREST THAT MAY ARISE AS PART OF INTERRELATIONSHIPS RESULTING FROM THEIR PROFESSIONAL CAREERS, THEIR FAMILIES, THEIR PERSONAL ACQUAINTANCES WITH KEY EMPLOYEES OF THE HOSPITAL, AND THEIR DUTIES AS A BOARD MEMBER. MONITORING IS CONDUCTED ON AN ONGOING BASIS, WITH THE EXPECTATION THAT BOARD MEMBERS WILL MEET THEIR AFFIRMATIVE OBLIGATION TO REPORT CONFLICTS OF INTEREST PRIOR TO THE EXECUTION OF BOARD TRANSACTIONS INVOLVING SUCH CONFLICTS. CHARLEVOIX AREA HOSPITAL CONSISTENTLY MONITORS AND ENFORCES COMPLIANCE WITH ITS CONFLICT OF INTEREST POLICY BY DISTRIBUTING AN ANNUAL CONFLICT OF INTEREST QUESTIONNAIRE TO BOARD MEMBERS, EMPLOYED PHYSICIANS, AND KEY EMPLOYEES, WHICH INCLUDES QUESTIONS RELATED TO EACH POLICY PROVISION. RESPONSES ARE THOROUGHLY REVIEWED AND ANY APPARENT CONFLICTS ARE THOROUGHLY INVESTIGATED. IN THE EVENT THAT A POTENTIAL CONFLICT IS IDENTIFIED PRIOR TO ACTION ON A CONTRACT OR TRANSACTION, THE CONFLICTED PERSON IS NOT ALLOWED TO PARTICIPATE IN DISCUSSIONS ON THE MATTER, NOT ALLOWED TO VOTE ON THE MATTER, AND NOT ALLOWED TO BE PRESENT DURING VOTING ON THE MATTER. Form 990, Part VI, Section B, line 15a THE HIGHEST PAID EMPLOYEES ARE PHYSICIANS, AND THE MGMA ANNUAL PHYSICIAN COMPENSATION SURVEY IS USED TO DETERMINE THAT SALARIES PAID TO OUR EMPLOYED PHYSICIANS ARE APPROPRIATE. EXECUTIVE COMPENSATION FOR THE CEO IS CHECKED AGAINST REGIONAL COMPENSATION THROUGH THE USE OF A WELL-RESPECTED EMPLOYMENT AND RECRUITING FIRM IN MICHIGAN. IT IS ALSO COMPARED TO COMPENSATION DATA PROVIDED BY OUR STATE HOSPITAL ASSOCIATION. THEIR REVIEW IS PERFORMED ANNUALLY BY THE COMPENSATION COMMITTEE OF THE BOARD. THIS REVIEW WAS LAST PERFORMED IN FISCAL YEAR 2009. 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. Form 990, Part XI, Line 2C THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE FINANCIAL STATEMENT AUDIT. Charlevoix Area Hospital Foundation 14700 Lake Shore Drive Charlevoix MI 49720 753078034 Fundraising MI 501(c)(3) Line 11a, I N/A 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 Charlevoix Area Hospital Foundation C 286035 Charlevoix Area Hospital Foundation N 41102