2011-11-14T16:13:31-07:00 2010-12-31 990 2010-01-01 391028081 BELOIT HEALTH SYSTEM INC BELO 6083645011 1969 West Hart Road Beloit WI 53511 William Groeper 6083645281 2011-11-14 2010 2016-02-24 21:20:13Z Gregory K Britton 1969 West Hart Road Beloit WI 53511 182535950 0 X www.beloithealthsystem.org X 1965 WI The mission of Beloit Health System is to be a leader in assembling medical, employee, equipment, facility, and community resources in a manner which strives to deliver the highest quality medical and wellness services and improves the overall health status of the community we serve. As Beloit Health System, these services will be delivered at an economic value and in a manner which creates the highest level of patient satisfaction. 13 5 1639 425 289041 289041 0 0 120322003 177222838 843226 817049 3799273 4496063 124964502 182535950 0 0 0 0 65903761 107711789 0 0 0 53481161 67559452 119384922 175271241 5579580 7264709 175759691 191593671 107362883 113912312 68396808 77681359 Beloit Health System provides quality medical health care regardless of race, creed, sex, national origin, disability, age or ability to pay. During 2010, the System's Hospital served over 4,400 inpatients and provided more than 505,000 outpatient services, the NorthPointe facility provided more than 71,000 outpatient services and the Clinics had over 225,000 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 44442445 54908370 Inpatient Revenue: Total admissions of 4,466 with an average daily census of 50. This was a slight 1% decrease from 2009 mainly due to the continued economic uncertainty from 2009 throughout 2010. Total patient days were 18,233 98459309 122025426 Outpatient Revenue: Beloit Memorial Hospital successfully integrated with the Beloit Clinic in 2010 to create the Beloit Health System. This integration of services substantially increased the number of outpatient services performed from 2009 to 2010. Total outpatient procedures were 578,495, an increase of 9% from the previous year. Total Clinic encounters were 226,787, all new outpatient service revenue for 2010. 0 0 0 142901754 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 1639 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 Memorial Hospital 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 361491 0 15925 Gregory K Britton 40 X X 526768 0 735709 Suzanne Anderson 0 X 0 0 0 Leo Egbujiobi MD 40 X 977925 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 354696 0 15925 Mario Rojas MD 40 X 511532 0 15925 Bill Sullivan 40 X X 251356 0 15925 Timothy M McKevett 40 X 279708 0 87361 William Groeper 40 X 201008 0 21980 Doris Mulder 40 X 208882 0 96030 Leland From MD 20 X 131992 0 16818 Kristinn Armann 40 X 116300 0 68800 Emmy Ho MD 40 X 846588 0 15925 Paul Segal MD 40 X 789041 0 15925 Tsu-Hon Wang MD 40 X 708675 0 15925 Ajmal Matloob 40 X 615392 0 15925 Glenn Tan MD 40 X 556090 0 15925 7437444 0 1185948 89 0 1 0 JP Cullen & Sons Inc 330 E Delavan Drive Janesville WI 53546 Construction Contractors 2222620 Power Wellness Management LLC 2055 W Army Trail Road Suite 124 Addison IL 60101 Wellness Operations Contractor 1018963 Clear Choice Transcription LLC PO Box 643455 Cincinnati OH 452643455 Transcription Services 676984 Southern WI Emergency Association 1664 N Randall Janesville WI 53545 Trauma Physicians 582043 Guenther Electric Inc 220 Liberty Avenue Beloit WI 53511 Electrical Contractors 400045 15 0 Outpatient Service Revenue 622000 122025427 122025427 0 0 Inpatient Service Revenue 622000 54908370 54908370 0 0 Third Party Administration 524292 289041 0 289041 0 0 0 0 0 177222838 812049 0 0 812049 0 0 0 0 0 0 0 0 284982 0 0 0 284982 0 284982 0 0 284982 0 5000 0 0 0 5000 5000 0 0 5000 Wellness Center & Spa Revenue 622000 2812778 0 0 2812778 Cafeteria & Snack Shop Revenue 622000 544497 0 0 544497 Physician Billing 622000 176016 0 0 176016 677790 0 0 677790 4211081 182535950 176933797 289041 5313112 76708562 63324003 13384559 6097497 5030435 1067062 20176452 16645573 3530879 4729278 3901654 827624 10935 10935 59200 59200 5674995 4643520 1031475 1173649 962392 211257 25713875 23287497 2426378 842737 842737 5920928 4855161 1065767 377328 207089 170239 19886 8305 11581 2716000 2716000 9941096 8151699 1789397 849230 849230 Equipment rental and maintenance 6443733 3130735 3312998 Other purchased services 3065468 893667 2171801 Collection expense 379717 0 379717 Professional memberships 158638 82757 75881 WI Provider Tax 4212037 4212037 0 175271241 142901754 32369487 0 6935 9035 11551634 15808573 12669481 25058445 642519 812752 2054723 2432468 2869657 2113888 185446369 83728429 86093095 101717940 31526014 32884646 3580000 28345633 7175924 175759691 191593671 11856617 19770232 2283635 3245545 49465000 70365000 22966841 2387255 20790790 18144280 107362883 113912312 X 68396808 77681359 0 0 0 0 68396808 77681359 175759691 191593671 X 7264709 2019842 X 0 1 1 X 0 X 1700000 5865455 7565455 0 102651081 30866891 71784190 0 5883752 2407208 3476544 0 69250277 50454330 18795947 0 95804 0 95804 101717940 0 Pension Liability 11127978 Interest Rate Swap Agreements 6663871 Capitalized Leases 352431 18144280 182535950 175271241 7264709 0 0 0 0 -3901006 -3901006 3363703 187608894 0 0 0 182663 182663 187426231 0 -4890281 -4890281 182535950 184245191 0 0 0 8973950 8973950 175271241 0 0 0 175271241 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 position, 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 assets or liabilities related to uncertain tax positions in 2010 and 2009. Federal tax returns for the years ended 2007 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 Assets for $182,663 minus the change in market value of the Interest Rate Swap Agreements ($401,567) and minus the Loss on Early Retirment of Bond Debt ($3,682,102). All nonoperating items are not included on Form 990 Statement of Revenue and Functional Expenses. Total Other is ($3,901,006) SchD_P12_S00_L02d Schedule D, Part XII, Line 2d Change in market value on Pension Restoration Assets $182,663 included as non operating income on audited financial statements and thus not included on Form 990 Statement of Revenue SchD_P12_S00_L04b Schedule D, Part XII, Line 4b Bad debt expense of $4,890,281 is netted against gross program service revenue on Form 990. This is shown as an operating expense on the audited financial statements SchD_P13_S00_L02d Schedule D, Part XIII, Line 2d Total is derived from Bad debt expense of $4,890,281 that is included as operating expenses on audited financial statements but netted against gross program service revenue on Form 990. Plus the Loss on Early Retirement of Bond Debt of $3,682,103 and the negative change in value of Interest Rate Swap Agreements of $401,566 are non operating expenses and not included the Statement of Functional Expenses. Total Other is $8,973,950 1 1 1 X 1 X 1 1 1 0 1 1 11167580 0.064 31165388 16806434 14358954 0.082 0 0 31165388 16806434 25526534 0.146 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 31636206 16815496 25988290 0.148 1 2019688 0 27547185 116970019 -89422834 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

Outpatient physician clinic Northpointe Health and Wellness

5605 E Rockton Road Roscoe IL 61073

Other outpatient physician 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 E 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

Outpatient 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 for 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 The carrying amounts of accounts receivable are reduced by allowances that reflect management's best estimate of the amounts that will not be collected. Management provides for contractual adjustments under terms of third-party reimbursement agreements through a reduction of gross revenue and a credit to a valuation allowance based on its assessment of historical collection likelihood and the current status of individual accounts. Balances that are still outstanding after management has used reasonable collection efforts are written off through a charge to valuation allowance and a credit to patient accounts receivable. Costing methodology used to determine bad debt expense at cost was the Ratio of Patient Care Cost to Charges wth guidance from the IRS worksheets in the instructions. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 Costing methodoloy used for Medicare allowable costs came directly off the 2010 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 or 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 satifactory 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 are 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 date. 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 other 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 the Rock County Health Needs Assessment Task Force which has been established for this purpose and meets on a monthly basis. Beloit Health System has 2 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 Wisconsin-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. They 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 in 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 in the area remains high and for 2010, Rock County, WI had an unemployment rate of 11.4% and Winnebago County, IL had an unemployment rate of 16.1%. Sources of Beloit Health System's gross patient revenue are 45.5% Medicare, 15.4% Medicaid, 5.0% Self Pays, and 34.1% Other Insurances. SchH_P06_S00_L05 Schedule H, Part VI, Line 5 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 volunteeing their time. In 2010, Beloit Health System doctors volunteered over 250 hours of service which resulted in 375 patients served. In addition to that, certain doctors volunteered their services for Operation Hope (a local program organized by a local church). 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 383042 0 143726 0 0 0 735709 0 0 0 1262477 0 684373 0 Leo Egbujiobi MD 944818 0 0 0 33107 0 15925 0 0 0 993850 0 0 0 Emmy Ho MD 846588 0 0 0 0 0 15925 0 0 0 862513 0 0 0 Paul Segal MD 789041 0 0 0 0 0 15925 0 0 0 804966 0 0 0 Tsu-Hon Wang MD 708675 0 0 0 0 0 15925 0 0 0 724600 0 0 0 Ajmal Matloob 615392 0 0 0 0 0 15925 0 0 0 631317 0 0 0 Glenn Tan MD 553058 0 0 0 3032 0 15925 0 0 0 572015 0 0 0 Mario Rojas MD 511532 0 0 0 0 0 15925 0 0 0 527457 0 0 0 Russel Albert MD 353808 0 0 0 7683 0 15925 0 0 0 377416 0 0 0 Tejesh Patel MD 330696 0 0 0 24000 0 15925 0 0 0 370621 0 0 0 Timothy M McKevett 234942 0 44766 0 0 0 87361 0 0 0 367069 0 326627 0 Doris Mulder 175461 0 33421 0 0 0 96030 0 0 0 304912 0 258464 0 Bill Sullivan 251346 0 0 0 0 0 15925 0 0 0 267271 0 0 0 William Groeper 189008 0 12000 0 0 0 21980 0 0 0 222988 0 0 0 Kristinn Armann 116300 0 0 0 0 0 68800 0 0 0 185100 0 0 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 0 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 0 1 0 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 Members serving as key employees and board members of interested party 0 Bank accounts and normal business banking 0 Marshall & Ilsley Trust Co An entity with a System board member serving as key employee of interested party 0 Trustee for Hospital Pension Plans 0 Regal Beloit Corp An entity with a System board member serving as CEO of interested party 0 Medical claims 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 transactions are considered to be in ther 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_L11a Form 990, Part VI, Section B, Line 11a 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 conflicts of interests to their immediate supervisor or Human Resources. It is the responsiblity 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 CEOs 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 continuously 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: $4,840,198 Cumulative effect of Swap termination: $838,518. Net assets released from restrictions and contributions for capital improvements: $784,331. Change in net unrealized gains and losses on investments other than trading securities: $780,417. Change in market valuation of Retirement Supplement Agreement: $182,664. Foundation receivable write-down: $(81,693). Change in market valuation of Swap agreements: $(401,567). Change in fair value of effective portion of interest rate swap agreements: $(1,240,923). Loss on early retirement of bond debt: $(3,682,103). 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 509112 Actual cash received from Beloit Health System Foundation Beloit Health System Foundation Inc o 81693 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