2011-08-15T13:18:30-05:00 2010-09-30 BODKIN WILSON & KOZICKI PLLC 204 THREE SPRINGS DR STE C WEIRTON WV 26062 990 2009-10-01 340714643 BELMONT COMMUNITY HOSPITAL BELM 7406711200 4697 HARRISON STREET BELLAIRE OH 43906 JAMES B MURDY 3042433681 2011-08-11 DAN E WILSON CPA 3047485550 2011-08-10 2009 2016-02-24 21:20:13Z RONALD VIOLI 1 MEDICAL PARK WHEELING WV 26003 25048602 0 X WWW.WHEELINGHOSPITAL.ORG X 1903 OH TO PROVIDE NEEDED CARE TO THE COMMUNITY REGARDLESS OF AN INDIVIDUAL'S ABILITY TO PAY. 7 6 307 16 2721359 -166597 29967 15425 20434962 21605128 17641 4687 3222888 3074185 23705458 24699425 0 0 11030688 10956520 0 0 13558037 14703791 24588725 25660311 -883267 -960886 12260471 10728816 3954927 4357446 8305544 6371370 BELMONT COMMUNITY HOSPITAL PROVIDES QUALITY MEDICAL HEALTHCARE TO PATIENTS FROM BELMONT COUNTY AND SURROUNDING COMMUNITIES REGARDLESS OF RACE, CREED, SEX, SEXUAL ORIENTATION, NATIONAL ORIGIN, HANDICAP, AGE OR ABILITY TO PAY. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATIONS AND STABILITY OF THE HOSPITAL, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PAY FOR ESSENTIAL MEDICAL SERVICES, AND OUR MISSION IS TO SERVE THE COMMUNITY WITH RESPECT TO PROVIDING HEALTHCARE EDUCATION. THEREFORE, IN KEEPING WITH BELMONT COMMUNITY HOSPITAL'S COMMITMENT TO SERVE ALL MEMBERS OF ITS COMMUNITY, FREE CARE OR SUBSIDIZED CARE, CARE PROVIDED TO PERSONS COVERED BY GOVERNMENT PROGRAMS AT OR BELOW COST, AND HEALTH ACTIVITIES AND PROGRAMS TO SUPPORT THE COMMUNITY WILL BE CONSIDERED WHERE THE NEED AND/OR INDIVIDUAL'S INABILITY TO PAY TO COEXIST. 0 0 24060412 21776358 BELMONT COMMUNITY HOSPITAL SERVED 1,298 INPATIENTS AND 55,057 OUTPATIENTS DURING THE PERIOD OCTOBER 1, 2009 THROUGH SEPTEMBER 30, 2010. 24060412 1 1 0 1 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 51 0 1 307 1 1 1 0 0 0 0 0 0 0 0 7 6 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 0 1 1 1 0 OH X JAMES B MURDY CFO 3042433681 ONE MEDICAL PARK WHEELING WV 26003 X JAMES E ALTMEYER SR 1.00 X 0 0 0 ROBERT A BITTENGLE 1.00 X 0 0 0 HARRY W WHITE 1.00 X 0 0 0 C GARY HILL 1.00 X 0 0 0 RICHARD M POLINSKY 1.00 X 0 0 0 NELLIE T MAGYAR 1.00 X 0 0 0 JAMES B MURDY 40.00 X 0 193482 24864 SUSAN FALBO 40.00 X 0 167679 20735 CHARLES L GEIGER DO 40.00 X 212750 0 10264 SHASHI GUPTA 40.00 X 224529 0 8254 CHAGANLAL PATEL 40.00 X 188511 0 7604 MARWAN YANES 40.00 X 178135 0 270 JUSTITO CANDARI 40.00 X 163411 0 11029 967336 361161 83020 11 0 1 0 PHYSICIAN PROVIDERS INC 4485 TENCH RD SUITE 2320 SUWANEE GA 30024 PHYSICAN SERVICES 134973 1 5500 9925 15425 GROSS PATIENT REVENUE 623990 46348577 46348577 CHARITY CARE 623990 -1046038 -1046038 CONTRACTUAL ALLOWANCE 623990 -23697411 -23697411 21605128 4687 4687 519973 10800 349177 170796 10800 181596 181596 OUTPATIENT PHARMACY 446110 2721359 2721359 171230 171230 2892589 24699425 21776358 2721359 186283 8860401 8795602 64799 23349 23179 170 1433020 1422658 10362 639750 630907 8843 139386 5000 134386 9904 9904 80846 80846 855 855 4888881 4787753 101128 150944 150944 458912 458912 51643 32974 18669 50273 50273 687650 687650 525962 525962 PURCHASED SERVICES 4739118 3951599 787519 BAD DEBT EXPENSE 1881113 1881113 OTHER EXPENSES 866294 672667 193627 MEDICAL SERVICES 86107 86107 DUES, BOOKS, SUBSCRIPTI 85903 48056 37847 25660311 24060412 1599899 0 1704287 764614 100178 100273 2751046 2844730 911452 775383 207786 254961 19023324 14195091 4643598 4828233 1416610 468600 525514 692022 12260471 10728816 3290116 3943929 664811 413517 3954927 4357446 X 7060358 6074472 56695 57986 1188491 238912 8305544 6371370 12260471 10728816 X 1 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 0 0 1 855 855 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: BELMONT COMMUNITY HOSPITAL IS A MEMBER OF THE OHIO HOSPITAL ASSOCIATION AND PAYS ANNUAL DUES. FOR 2010, THE PERCENTAGE OF OHA DUES RELATED TO LOBBYING ACTIVITIES IS 5%. 264684 264684 7949517 5704695 2244822 10337159 8179110 2158049 471964 311286 160678 4828233 MELLOTT TRUST RECEIVABLE 6475 OTHER RECEIVABLE 34055 AMOUNTS DUE 3RD PARTY PAYORS 504759 ACUITY RECEIVABLE 145855 WHEELING HOSPITAL PHYSICIAN RENT RECEIVABLE 693 INSURANCE SURPLUS 185 692022 24699425 25660311 -960886 -973288 -973288 -1934174 24892358 -69573 -69573 24961931 -262506 -262506 24699425 25853244 262506 262506 25590738 69573 69573 25660311 Part XI, Line 8 - Other Adjustments: REVALUATION OF PERMANENTLY RESTRICTED FOR OTHER-THAN-TEMPORARY IMPAIRMENT: -949579. CONTRIBUTED CAPITAL: -25000. TEMPORARILY RESTRICTED CONTRIBUTIONS: 1291. Part XII, Line 2d - Other Adjustments: RETAIL PHARMACY CONTRA REVENUE: -69573. Part XII, Line 4b - Other Adjustments: LEASEHOLD RENTAL EXPENSE: -262506. Part XIII, Line 2d - Other Adjustments: LEASEHOLD RENTAL EXPENSE: 262506. Part XIII, Line 4b - Other Adjustments: RETAIL PHARMACY CONTRA REVENUE: 69573. 1 1 1 X 1 X 1 1 0 0 433374 341804 91570 0.00390 2483801 1940493 543308 0.02280 2917175 2282297 634878 0.02670 6469 6469 0.00030 6469 6469 0.00030 2923644 2282297 641347 0.02700 779345 17820 4305515 4798084 -492569 X 1 1 BELMONT COMMUNITY HOSPITAL

4697 HARRISON STREET BELLAIRE OH 43906

X X X Part I, Line 7: THE COST-TO-CHARGE RATIO FROM WORKSHEET C OF THE 12/31/09 CMS COST REPORT WAS USED TO CALCULATE THE AMOUNTS REPORTED IN THE TABLE. THIS RATIO ADDRESSES ALL PATIENT SEGMENTS. Part I, Line 7f: $1,881,113 OF BAD DEBT EXPENSE WAS INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT WAS SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN COLUMN F. Part III, Line 4: THE COST-TO-CHARGE RATIO FROM WORKSHEET C OF THE 12/31/09 CMS COST REPORT WAS USED TO CALCULATE THE AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE AT COST REFLECTED ON LINE 2. THIS RATIO WAS APPLIED TO THE TOTAL BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A).THE ESTIMATED AMOUNT OF BAD DEBT EXPENSE THAT COULD REASONABLY BE ATTRIBUTABLE TO PATIENTS WHO LIKELY WOULD QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE HOSPITAL'S CHARITY CARE POLICY WAS CALCULATED BY APPLYING THE PERCENTAGE OF CHARITY TO GROSS PATIENT REVENUE TO THE TOTAL BAD DEBT EXPENSE AT COST.BELMONT COMMUNITY HOSPITAL DOES NOT HAVE SEPARATE AUDITED FINANCIAL STATEMENTS SO THERE IS NO TEXT OF THE BAD DEBT EXPENSE FOOTNOTE TO PROVIDE. THE BAD DEBT REFLECTED ON THE FINANCIAL STATEMENTS IS THE GROSS AMOUNT OF THE ACCOUNTS DEEMED UNCOLLECTIBLE. THIS WOULD BE FOR ACCOUNTS THAT HAVE HAD NO PAYMENT FOR 60 DAYS AND HAVE HAD A MINIMUM OF STATEMENTS PRODUCED. THEREFORE, THE BAD DEBT AMOUNTS WOULD BE AFTER ANY DISCOUNTS OR PATIENT PAYMENTS HAVE BEEN APPLIED. Part III, Line 8: THE COSTS REFLECTED IN LINE 6 ARE THE ALLOWABLE COSTS FROM WORKSHEET D-1 OF THE 12/31/09 CMS COST REPORT. THIS REPORT WAS USED AS BELMONT COMMUNITY HOSPITAL'S COST REPORT IS FILED ON A CALENDAR YEAR BASIS, AND 12/31/09 CMS COST REPORT IS THE CALENDAR YEAR FILING THAT WOULD FALL IN THE FISCAL YEAR REPORTED ON FORM 990. NONE OF THE SHORTFALL ON LINE 7 IS TREATED AS COMMUNITY BENEFIT. DESPITE THE FACT THAT THE PROGRAM SERVICES ALL ELDERLY AND DISABLED BENEFICIARIES AND COULD REPRESENT COMMUNITY BENEFIT, IT IS NOT TREATED AS COMMUNITY BENEFIT TO BE CONSISTENT WITH THE PRESENTATION OF THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS. Part III, Line 9b: BELMONT COMMUNITY HOSPITAL'S COLLECTION POLICY HAS BEEN ESTABLISHED TO DEFRAY THE COSTS OF MEDICALLY NECESSARY SERVICES FOR THOSE PATIENTS WHO MEET CERTAIN GUIDELINES AND HAVE NO OTHER MEDICAL FUNDING SOURCES. INPATIENT, OUTPATIENT, EMERGENCY ROOM SERVICES, PROFESSIONAL SERVICES OF EMPLOYED PHYSICIANS AND PRESCRIPTION DRUGS ON AN ACUTE/EMERGENT BASIS ARE ELIGIBLE FOR FINANCIAL ASSISTANCE/CHARITY CARE. THE FINANCIAL ASSISTANCE/ CHARITY CARE APPLICATION MUST BE SIGNED BYTHE APPLICANT ATTESTING TO THE TRUTHFULNESS AND ACCURACY OF THE INFORMATION PROVIDED. CERTAIN DENIAL LETTERS ARE REQUIRED IN ORDER TO BE ELIGIBLE FOR CHARITY CARE. ELIGIBILITY IS DETERMINED BY REFERENCING THE FINANCIAL ASSISTANCE/ CHARIY CARE MATRIX, WHICH IS BASED ON THE FEDERAL POVERTY GUIDELINES FOR THE MOST CURRENT YEAR AVAILABLE. THOSE APPROVED APPLICANTS WHO ARE AT OR BELOW 100% OF THE FEDERAL POVERTY GUIDELINES AND HAVE PROVIDED THE REQUIRED DOCUMENTATION ARE ELIGIBLE TO RECEIVE CHARITY CARE, AND THOSE WHO ARE FROM 101% TO 300% OF THOSE LIMITS ARE ELIGIBILE FOR DISCOUNTS. Part VI, Line 2: BELMONT COMMUNITY HOSPITAL CURRENTLY HAS A FIRM ENGAGED TO PERFORM A NEEDS ASSESSMENT. NO ASSESSMENT WAS PERFORMED DURING OCTOBER 1, 2009 TO SEPTEMBER 30, 2010. Part VI, Line 3: INFORMATION IS INCLUDED ON THE BACK OF PATIENT INVOICES REGARDING THE HCAP PROGRAM. SELF PAY ACCOUNTS OVER $500 ARE SCREENED BY THE MASH SERVICE OFF SITE FOR GOVERNMENT PROGRAM ELIGIBILITY. IN ADDITION, SELF PAY PATIENTS ARE CONTACTED BY THE PATIENT ACCOUNTING DEPARTMENT TO DISCUSS MEANS OF PAYMENT. IF THE PATIENT STATES THAT THEY DO NOT HAVE THE MEANS TO PAY, BCH STAFF REVIEWS OTHER OPTIONS, SUCH AS PAYMENT PLAN, CHARITY OR DISCOUNT. Part VI, Line 4: BELMONT COMMUNITY HOSPITAL PREDOMINANTLY SERVICES THE WHEELING METROPOLITAN STATISTICAL AREA. THE PRIMARY SERVICES AREA INCLUDES ONE COUNTY IN THE NORTHERN PANHANDLE OF WEST VIRGINIA (OHIO COUNTY) AND ONE COUNTY IN OHIO (BELMONT COUNTY), WITH A TOTAL POPULATION OF APPROXIMATELY 112,000.THE RACIAL MAKEUP OF THE MSA AS OF THE 2000 CENSUS WAS 95.62% WHITE, 2.87% AFRICAN AMERICAN, 0.44% ASIAN, 0.12% NATIVE AMERICAN, WITH THE REMAINDER FROM OTHER RACES OR A COMBINATION OF TWO OR MORE RACES. THE MEDIAN HOUSEHOLD INCOME FOR 2008 WAS APPROXIMATELY $38,000. THE BELOW POVERTY LEVEL PERCENTAGE FOR 2008 WAS APPROXIMATELY 16%. Part VI, Line 6: A MAJORITY OF THE HOSPITAL'S BOARD MEMBERS ARE RESIDENTS OF THE PRIMARY SERVICE AREA AND ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE HOSPITAL.IN ADDITION, THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ANY QUALIFIED PHYSICIAN IN THE COMMUNITY. Part VI, Line 7: BELMONT COMMUNITY HOSPITAL IS AN AFFILIATE OF WHEELING HOSPITAL, OFFERING PRIMARY CARE AND SELECTED SPECIALITY SERVICES FOR THE RESIDENTS OF THE UPPER OHIO VALLEY. X X X X 0 0 0 1 0 0 0 0 0 JAMES B MURDY 0 166361 0 20101 0 7020 0 10996 0 13868 0 218346 0 0 SUSAN FALBO 0 136078 0 25101 0 6500 0 6959 0 13776 0 188414 0 0 CHARLES L GEIGER DO 105381 0 90880 0 16489 0 2027 0 8237 0 223014 0 0 0 SHASHI GUPTA 184349 0 18189 0 21991 0 2244 0 6010 0 232783 0 0 0 CHAGANLAL PATEL 163511 0 0 0 25000 0 1594 0 6010 0 196115 0 0 0 MARWAN YANES 178135 0 0 0 0 0 0 0 270 0 178405 0 0 0 JUSTITO CANDARI 146491 0 0 0 16920 0 1633 0 9396 0 174440 0 0 0 Supplemental Information Part III 5a: GEIGER, PATEL AND GUPTA RECEIVE INCENTIVE COMPENSATION BASED ON CASH RECEIPTS. PART II: THE REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS FOR JAMES B MURDY IS FOR SERVICES RENDERED AS CFO FOR THE FILING ORGANIZATION AND THE RELATED ORGANIZATION. THE MAJORITY OF HIS TIME IS SPENT AT THE RELATED ORGANIZATION. PART II: THE REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS FOR SUSAN FALBO IS FOR SERVICES RENDERED AS VP OF HUMAN RESOURCES FOR THE FILING ORGANIZATION AND THE RELATED ORGANIZATION. THE FILING ORGANIZATION REIMBURSES THE RELATED ORGANIZATION FOR A PORTION OF THESE WAGES MONTHLY. Form 990, Part VI, Section B, line 11 AN OUTSIDE CPA FIRM IS HIRED TO REVIEW THE 990. Form 990, Part VI, Section B, line 12c ALL MEMBERS OF THE BOARD OF DIRECTORS AND OFFICERS RECEIVE A COPY OF THE CONFLICT OF INTEREST POLICY ANNUALLY. RECIPIENTS ARE ANNUALLY ASKED TO ACKNOWLEDGE THEY HAVE READ THE POLICY, IDENTIFY ANY AREAS OF CONFLICT AND RETURN THE SIGNED DISCLOSURE FORM TO BELMONT COMMUNITY HOSPITAL. RESPONSES ARE REVIEWED AND IDENTIFIED. CONFLICTS ARE REFERRED TO THE BOARD OF DIRECTORS FOR DISCUSSION AND APPROVAL. EMPLOYEES ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE AT HIRING AND WHEN A CHANGE OCCURS THAT MAY BE A CONFLICT OF INTEREST. Form 990, Part VI, Section B, line 15 OFFICERS AND KEY EMPLOYEES COMPENSATION IS REVIEWED BY A BELMONT COMMUNITY HOSPITAL COMMITTEE. THE COMMITTEE REVIEWS NATIONAL, REGIONAL AND LOCAL COMPENSATION SURVEYS. ADDITIONALLY, YEARS OF SERVICE ARE ALSO TAKEN INTO ACCOUNT. Form 990, Part VI, Section C, line 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. FORM 990, PART XI, LINE 2C: THE PROCESS HAS NOT CHANGED. PART VII, SECTION A, 1A (E) THE REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS FOR JAMES B MURDY IS FOR SERVICES RENDERED AS CFO FOR THE FILING ORGANIZATION AND THE RELATED ORGANIZATION. THE MAJORITY OF HIS TIME IS SPENT AT THE RELATED ORGANIZATION. THE REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS FOR SUSAN FALBO IS FOR SERVICES RENDERED AS VP OF HUMAN RESOURCES FOR THE FILING ORGANIZATION AND THE RELATED ORGANIZATION. THE FILING ORGANIZATION REIMBURSES THE RELATED ORGANIZATION FOR A PORTION OF THESE WAGES MONTHLY. WHEELING HOSPITAL INC ONE MEDICAL PARK WHEELING WV 26003 550357057 HOSPITAL WV 501C(3) 3 BELMONT COMMUNITY HOSPITAL AUXILIARY 4697 HARRISON STREET BELLAIRE OH 43906 346567473 FUNDRAISING FOR HOSPITAL OH 501C(3) 9 0 0 1 0 1 0 0 0 1 0 1 1 0 1 1 1 0 1 WHEELING HOSPITAL E 133146 WHEELING HOSPITAL I 55729 WHEELING HOSPITAL K 105581 WHEELING HOSPITAL L 466985 WHEELING HOSPITAL N 1564863 WHEELING HOSPITAL O 2402726 WHEELING HOSPITAL P 317504 WHEELING HOSPITAL R 404957