2023-11-09T09:49:02-06:00 2022-12-31 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2022-01-01 390845590 MEMORIAL HOSPITAL OF BOSCOBEL MEMO 6083754112 205 PARKER STREET BOSCOBEL WI 53805 JENNIFER BOIGENZAHN FINANCE ADMINISTRATOR 6083754112 2023-10-31 1 JENNIFER BOIGENZAHN 999009999 1 MICHAEL J PETERSON CPA P01833529 2187224705 2023-10-31 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS JENNIFER BOIGENZAHN 205 PARKER STREET BOSCOBEL WI 53805 29338830 0 X WWW.GUNDERSENHEALTH.ORG/BOSCOBEL X 1952 WI WE WILL IMPROVE THE HEALTH OF OUR COMMUNITY THROUGH EXCELLENCE IN HIGH QUALITY, PATIENT CENTERED CARE. 12 5 196 50 0 0 4784113 1250948 26421105 27756390 73229 219400 109234 112092 31387681 29338830 0 0 0 0 11740560 13020556 0 0 0 12292214 13713046 24032774 26733602 7354907 2605228 33102930 31544684 5331744 2571842 27771186 28972842 X WE WILL ENHANCE THE HEALTH AND WELL-BEING OF OUR COMMUNITIES WHILE ENRICHING EVERY LIFE WE TOUCH, INCLUDING PATIENTS, FAMILIES, AND STAFF. 0 0 17932754 0 23786389 GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS ("THE ORGANIZATION") PROVIDES INPATIENT, OUTPATIENT, EMERGENCY HEALTH CARE SERVICES AND OTHER FINANCIAL SUPPORT THROUGH VARIOUS PROGRAMS THAT ARE DESIGNED, AMONG OTHER MATTERS, TO ENHANCE THE HEALTH OF THE COMMUNITY INCLUDING THE HEALTH OF LOW-INCOME PATIENTS. SERVICES PROVIDED TO PATIENTS INCLUDE COLONOSCOPIES, LAPAROSCOPIC SURGERIES, AND KNEE REPLACEMENTS, AMONG OTHERS. THE ORGANIZATION IS AFFILIATED WITH GUNDERSEN HEALTH SYSTEM. THIS AFFILIATION PROVIDES LOCAL SERVICES IN CARDIOLOGY, NEUROLOGY, PODIATRY, DERMATOLOGY, UROLOGY, AND VASCULAR MEDICINE AS WELL AS MANY OTHER SERVICES. CONSISTENT WITH THE MISSION OF THE ORGANIZATION, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY, INCLUDING PROVIDING SERVICES TO THOSE PERSONS WHO ARE EITHER UNDERINSURED OR WHO CANNOT AFFORD HEALTH INSURANCE BECAUSE OF INADEQUATE RESOURCES. HEALTH CARE SERVICES TO PATIENTS UNDER GOVERNMENT PROGRAMS, SUCH AS THE MEDICAID PROGRAM, ARE ALSO CONSIDERED PART OF THE ORGANIZATION'S BENEFIT PROVIDED TO THE COMMUNITY, SINCE A SUBSTANTIAL PORTION OF SUCH SERVICES ARE REIMBURSED AT AMOUNTS LESS THAN THE COSTS OF PROVIDING CARE. (SEE ADDITIONAL INFORMATION REGARDING THE COST OF PROVIDING SERVICES TO MEDICAID PATIENTS IN SCHEDULE H OF THE FORM 990.) PATIENTS WHO MEET CERTAIN CRITERIA FOR CHARITY CARE, GENERALLY BASED ON FEDERAL POVERTY GUIDELINES, ARE PROVIDED CARE AT A SIGNIFICANTLY REDUCED RATE, DETERMINED BASED ON QUALIFYING CRITERIA AS DEFINED IN THE ORGANIZATION'S CHARITY CARE POLICY AND FORM APPLICATIONS COMPLETED BY PATIENTS AND THEIR FAMILIES. (SEE ADDITIONAL INFORMATION REGARDING THE COST OF PROVIDING SERVICES TO CHARITY CARE RECIPIENTS IN SCHEDULE H OF THE FORM 990.) BENEFITS FOR SERVING THE COMMUNITY ALSO INCLUDE UNPAID COSTS OF TREATING THE ELDERLY, HEALTH SCREENINGS, COMMUNITY EDUCATION THROUGH SEMINARS AND CLASSES, AND OTHER HEALTH-RELATED SERVICES. DURING 2022, THE HOSPITAL HAD 1,271 IN-PATIENT DAYS IN TOTAL. 5023 EMERGENCY ROOM CONTACTS. 450 SURGERIES, OVER 57,000 LAB TESTS AND OVER 9,000 IMAGING TESTS. 4316321 0 3977371 THE ORGANIZATION OPERATES FAMILY PRACTICE CLINICS IN THREE LOCATIONS TO ENSURE COMMUNITY MEMBERS HAVE ACCESS TO CONVENIENT, QUALITY PRIMARY CARE. DURING 2022, TOTAL OUTPATIENT ENCOUNTERS AT THESE CLINICS TOTALED 10,313. THE THREE CLINICS ARE DESIGNATED AS RURAL HEALTH CLINICS BY THE MEDICARE AND MEDICAID PROGRAMS AND BY DEFINITION PROVIDE HEALTH CARE TO AREAS DESIGNATED AS MEDICAL PROFESSIONAL SHORTAGE AREAS WHERE WITHOUT THESE CLINICS THERE WOULD BE LIMITED ACCESS TO PRIMARY CARE CLINICAL SERVICES. IN ADDITIONAL, THE ORGANIZATION'S CHARITY CARE PROGRAM IS ALSO AVAILABLE TO PATIENTS OF THE CLINICS AND IS INCLUDED IN THE CHARITY CARE AMOUNT REPORTED FOR THE HOSPITAL AS CHARITY CARE BENEFITS GIVEN TO CLINIC PATIENTS IN SCHEDULE H OF THE FORM 990. 22249075 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 57 0 1 196 1 0 0 0 0 0 0 0 0 0 0 0 0 X 12 5 0 0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X RONDA FOSTERLING 6083754112 205 PARKER STREET BOSCOBEL WI 53805 X ANDY NAHAS VICE PRESIDENT/GHS OPTOMETRIST 0.50 40.00 X X 0 228466 59933 KEITH FRYE SECRETARY/ADMIN DIR - LAB 0.50 40.00 X X 0 146381 52103 JERRY BERGE PRESIDENT 0.50 X X 0 0 0 SCOTT KNIPRATH VICE PRESIDENT/EXEC DIR (THRU JAN) 0.50 40.00 X X 0 3998 2127 ALAN EBER BOARD MEMBER/DIR OF BUS. SERV. 0.50 40.00 X 0 147001 54987 MARILU BINTZ MD BOARD MEMBER/MED VP GHS 0.50 40.00 X 0 620762 84326 KRAIG SCHUSTER BOARD MEMBER/VP GHS 0.50 40.00 X 0 284169 81188 JAMES KLOCK BOARD MEMBER/DIR OF REG IS 0.50 40.00 X 0 163144 57227 DAWN THORSTEN BOARD MEMBER/QUALITY DIRECTOR 0.50 40.00 X 0 118335 52541 GARY BOUGHTON BOARD MEMBER 0.50 X 0 0 0 PETE ESSER BOARD MEMBER 0.50 X 0 0 0 CYNDE LARSEN BOARD MEMBER 0.50 X 0 0 0 MICHELLE MUELLER BOARD MEMBER 0.50 X 0 0 0 THERESA BRAUDT ADMINISTRATOR 40.00 X 0 181200 63090 JENNIFER BOIGENZAHN FINANCE ADMINISTRATOR 40.00 X 0 140983 31215 MICHELLE PETERSON APNP FAMILY MEDICINE 40.00 X 113657 0 6669 TARA WOOD PHARMACIST 40.00 X 160892 0 30413 LISA WITTER PHARMACIST 40.00 X 126537 0 28212 401086 2034439 604031 15 0 1 0 WAPITI MEDICAL STAFFING 107 FLYNN DR STE 600 MILBANK SD 57252 MEDICAL STAFFING 2124190 STAFFENCY 221 W COLLEGE AVE FLR 2 APPLETON WI 54911 STAFFING SERVICE 800577 MEDICAL CONTRACTING SERVICES 10300 N CENTRAL EXPY DALLAS TX 75231 MEDICAL STAFFING 594209 KRAEMER BROTHERS LLC 928 PARK AVE PLAIN WI 53577 CONTRACTOR 428526 COMPHEALTH PO BOX 972651 DALLAS TX 75397 MEDICAL STAFFING 278333 18 1071634 179314 1250948 HOSPITAL PATIENT REVENUE 621110 23595391 23595391 CLINIC REVENUE 621110 3977371 3977371 PHARMACY REVENUE 456110 147131 147131 36497 36497 27756390 219400 219400 EHR INCENTIVE PAYMENTS 621990 7370 7370 104722 104722 112092 29338830 27763760 0 324122 X 416488 416488 10346821 8558410 1788411 242384 231592 10792 1436983 1191204 245779 577880 463561 114319 923781 923781 151378 151378 554 554 6303698 6173287 130411 126059 126059 343539 208668 134871 36350 36350 298809 275550 23259 68055 58767 9288 25045 15805 9240 3055 2413 642 976313 771287 205026 73018 73018 BILLABLE MEDICAL SUPPLI 2365652 2342492 23160 PROVISION FOR BAD DEBTS 1538544 1538544 EQUIPMENT RENTAL 222557 218195 4362 REPAIRS & MAINTENANCE 153801 153801 102838 45499 57339 26733602 22249075 4484527 0 25135 28988 22412778 20353262 2414267 2390063 384258 378389 250070 136259 23320902 16172594 6452706 7148308 11243 5621 1152473 1103794 33102930 31544684 1475862 1922214 7370 0 52768 174926 3795744 474702 5331744 2571842 X 26858730 28972842 912456 0 27771186 28972842 33102930 31544684 X 2605228 -1203951 -199621 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 6430 6430 0 PART II-B, LINE 1: GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS (THE ORGANIZATION") PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THESE DUES ARE PAID PRIMARILY TO ACCESS EDUCATIONAL MATERIALS AND FOR STAFF TRAINING. THE WHA HAS NOTIFIED THE ORGANIZATION THAT $1,457 OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTH CARE ENVIRONMENT. THE ORGANIZATION IS ALSO A MEMBER OF THE RURAL WISCONSIN HEALTH COOPERATIVE (RWHC). EACH YEAR THE ORGANIZATION PAYS MEMBERSHIP FEES TO RWHC. THE RWHC PROVIDES SUPPORT SERVICES FOR A NUMBER OF ITS MEMBER HOSPITALS THROUGHOUT THE STATE OF WISCONSIN. SOME OF THE MANY SERVICES PROVIDED TO MEMBER HOSPITALS INCLUDE PROVIDING ASSISTANCE TO ORGANIZATIONS IN FINDING GRANT FUNDING FOR NEW PROGRAMS, LEGAL SERVICES, REIMBURSEMENT REVIEW SERVICES, ACCOUNTING ASSISTANCE, CONTRACTING FOR THERAPIST COVERAGE, AND ADMINISTRATIVE CONSULTING SERVICES. AS A PART OF THESE SERVICES, RWHC ALSO PROVIDES AN ANALYSIS OF CURRENT HEALTH CARE ISSUES IN AN EFFORT TO PROMOTE AND BETTER HEALTHCARE FOR HOSPITALS IN RURAL COMMUNITIES THROUGHOUT WISCONSIN. ONE OF THESE EFFORTS ALSO INCLUDES A SMALL AMOUNT OF LOBBYING ON THE PART OF THE MEMBER HOSPITALS. THE RWHC DETERMINED THAT $2,165 OF THE FEES PAID BY THE ORGANIZATION IN 2022 RELATED TO LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE HEALTH CARE ENVIRONMENT IN THE STATE OF WISCONSIN. THE LOBBYING PORTION OF STATE AND NATIONAL MEMBERSHIP ASSOCIATIONS SUCH AS THE AMERICAN HOSPITAL ASSOCIATION (AHA): $2,808. 379666 379666 14401232 9691847 4709385 181608 15134 166474 8132370 6465613 1666757 226026 226026 7148308 3RD PARTY SETTLEMENTS PAYABLE 473849 PTO ACCRUED DONATION 853 474702 X PART X, LINE 2: THE SYSTEM HAS REVIEWED ITS TAX POSITIONS FOR ALL OPEN YEARS AND HAS CONCLUDED THAT NO LIABILITIES EXIST FOR UNCERTAIN TAX POSITIONS. THE SYSTEM'S INCOME TAX RETURNS ARE NO LONGER SUBJECT TO EXAMINATION FOR 2018 AND PRIOR YEARS. 1 1 X 1 X 1 X 1 1 0 1 1 146486 146486 0.00550 3676525 3302726 373799 0.01400 3823011 3302726 520285 0.01950 9520 9520 0.00040 38528 38528 0.00140 4349855 2424529 1925326 0.07200 9173 9173 0.00030 4407076 2424529 1982547 0.07410 8230087 5727255 2502832 0.09360 17254 17254 0.00060 1531 1531 0.00010 5831 5831 0.00020 2062 2062 0.00010 26678 26678 0.00100 0 710014 355007 6763895 6758766 5129 1 1 1 1 MEMORIAL HOSPITAL OF BOSCOBEL 205 PARKER STREET BOSCOBEL WI 53805 WWW.GUNDERSENHEALTH.ORG/BOSCOBEL 1048 X X X X MEMORIAL HOSPITAL OF BOSCOBEL 1 0 0 1 X X X X X X X X X 21 1 1 1 1 X SEE SUPPLEMENTAL INFORMATION X X 1 22 1 HTTP://WWW.GUNDERSENHEALTH.ORG/COMMUNITY-ASSESSMENT/ 0 1 X 200.000000000000 400.000000000000 X X X X X X X 1 1 X X X X 1 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X X X X X X 1 X 0 X X X X 1 X 0 0 MEMORIAL HOSPITAL OF BOSCOBEL PART V, SECTION B, LINE 5: INDIVIDUALS AND COMMUNITY MEMBERS REPRESENTING THEIR OWN INTERESTS WERE REACHED IN TWO WAYS: A GENERAL SURVEY COMPLETED VIA ON-LINE SOURCES, AT PUBLIC EVENTS AND FOCUS GROUPS. COMMUNITY MEMBERS COMPLETING THE WRITTEN SURVEY IDENTIFIED THEMSELVES BY AGE, GENDER, RACE, EDUCATION LEVEL, EMPLOYMENT STATUS AND NUMBER OF CHILDREN IN HOUSEHOLD. FOCUS GROUP PARTICIPANTS WERE IDENTIFIED BY GENDER. MEMORIAL HOSPITAL OF BOSCOBEL PART V, SECTION B, LINE 6A: THE CHNA WAS CONDUCTED IN JOINT EFFORT WITH THE FOLLOWING OTHER HOSPITALS:1. CROSSING RIVERS HEALTH2. GRANT REGIONAL HEALTH CENTER, INC. MEMORIAL HOSPITAL OF BOSCOBEL PART V, SECTION B, LINE 6B: THE CHNA WAS CONDUCTED IN JOINT EFFORT WITH THE FOLLOWING OTHER ORGANIZATIONS: MEMORIAL HOSPITAL OF BOSCOBEL 39-08455901. CRAWFORD COUNTY PUBLIC HEALTH DEPARTMENT2. GRANT COUNTY PUBLIC HEALTH DEPARTMENT3. CRAWFORD COUNTY UNIVERSITY OF WISCONSIN - EXTENSION4. GRANT COUNTY UNIVERSITY OF WISCONSIN - EXTENSION5. AGING AND DISABILITY RESOURCE CENTER - CRAWFORD AND GRANT COUNTIES MEMORIAL HOSPITAL OF BOSCOBEL PART V, SECTION B, LINE 7D: HTTP://WWW.GUNDERSENHEALTH.ORG/COMMUNITY-ASSESSMENT/ MEMORIAL HOSPITAL OF BOSCOBEL PART V, SECTION B, LINE 11: THE COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS REVEALED SEVERAL NEEDS IN OUR COMMUNITIES THAT CAN BE SUMMARIZED AS:1. THE NEED TO EMPOWER PEOPLE TO IMPROVE THEIR HEALTH THROUGH AWARENESS AND EDUCATION2. THE NEED TO CONNECT PEOPLE TO SERVICES AND RESOURCES3. THE NEED TO CREATE A HEALTHY ENVIRONMENT AND A CULTURE OF WELLNESS ACROSS THE LIFESPAN TO ADDRESS THESE NEEDS, GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS HAS IMPLEMENTED AN ACTION PLAN THAT INVOLVES SEVERAL PROGRAMS AND OUTREACH INITIATIVES. TO EMPOWER PEOPLE TO IMPROVE THEIR HEALTH, GUNDERSEN BOSCOBEL HAS IMPLEMENTED SEVERAL PROGRAMS AND INITIATIVES THAT OFFER COMMUNITY MEMBERS GREATER ABILITY TO IMPROVE THEIR HEALTH. FOR INSTANCE, UNCONSCIOUS BIAS TRAINING WAS IMPLEMENTED FOR ALL GUNDERSEN STAFF MEMBERS IN 2022 TO PREVENT BIAS AND INCREASE AWARENESS WHEN INTERACTING WITH PATIENTS. OUR CARE TEAM RECEIVED THIS EDUCATION TO ENSURE THAT WE CAN PROVIDE THE BEST POSSIBLE SUPPORT TO OUR PATIENTS AND THEIR FAMILIES. THE HOSPITAL ALSO OFFERS MOVIN' & MORE VOUCHERS, FUNDED THROUGH THE HOSPITAL FOUNDATION, THAT SUPPORT ONE COMPLIMENTARY MONTH IN THE PROGRAM FOR ALL CARDIOPULMONARY REHABILITATION GRADUATES. THROUGH THE VOUCHER, THIS PROGRAM WAS MADE MORE ACCESSIBLE TO PATIENTS WHO PREVIOUSLY OPTED NOT TO ENROLL DUE TO COST. MEMORIAL HOSPITAL OF BOSCOBEL 39-0845590 ALSO PROVIDES EDUCATIONAL SEMINARS AND TRAINING FOR COMMUNITY MEMBERS, EMPLOYERS, AND LOCAL ENTITIES, INCLUDING WHOLE-FAMILY WELLNESS, TRAUMA SUPPORT, MEDICATION RECONCILIATION, EMS TRAINING, CPR, AND MORE.SECONDLY, WE HAVE HELPED CONNECT PEOPLE TO SERVICES AND RESOURCES BY SIGNIFICANTLY IMPROVING ACCESS TO SPECIALTY PROVIDERS IN OUR RURAL AREA. THIS HAS ALLOWED RESIDENTS, MANY OF WHOM ARE LOW-INCOME OR ELDERLY, IMPROVED ACCESS TO SPECIALTY PROVIDERS THAT MAY HAVE BEEN DIFFICULT TO ACCESS WITH TRAVEL RESTRAINTS. A NEEDED PROGRAM THAT WAS NOTED IN THE 2021 COMMUNITY HEALTH NEEDS ASSESSMENT WAS MENTAL HEALTH ACCESS. THE HOSPITAL HAS ALSO ADDED A SECOND BEHAVIORAL HEALTH PROVIDER, A LICENSED CLINICAL SOCIAL WORKER, TO ADDRESS THE NEED FOR GREATER ACCESSIBILITY TO MENTAL HEALTH CARE. ADDITIONALLY, GUNDERSEN BOSCOBEL HAS EXPANDED VIRTUAL CARE AND TELEMEDICINE CAPABILITIES TO ALLOW FOR GREATER ACCESS TO FOLLOW-UP CARE WITH SPECIALTY PROVIDERS AND SERVICES NOT OFFERED AT THEIR LOCATION. THE HOSPITAL HAS ALSO PARTNERED WITH SECOND HARVEST FOOD BANK FOR THEIR FREE 12-MONTH-LONG HUNGERCARE WELLNESS PROGRAM, AIMED AT PATIENTS WITH FOOD INSECURITY, DIABETES OR HEART DISEASE. THIS PROGRAM PROVIDES PATIENTS WITH 30 POUNDS OF HEART-HEALTHY/DIABETES-FRIENDLY FOOD EACH MONTH, ALONG WITH EDUCATIONAL HANDOUTS AND RECIPES. IN TOTAL, GUNDERSEN BOSCOBEL SUPPORTED 36 PATIENTS IN THIS 12-MONTH PROGRAM PERIOD. LASTLY, GUNDERSEN BOSCOBEL HAS ENCOURAGED A HEALTHY ENVIRONMENT AND CULTURE OF WELLNESS BY COLLABORATING WITH OTHER COMMUNITY PARTNERS AND WELLNESS WORKSHOPS. THIS INCLUDES INITIATIVES SUCH AS SMOKING CESSATION, MEDICATION WASTE PROGRAM, SHARPS COLLECTION, BIKE SAFETY RODEO, GROCERY STORE TOURS, COUCH TO 5K WALK/RUN 8-WEEK WELLNESS PROGRAM, AS WELL AS COOKING CLASSES, FREE BLOOD PRESSURE SCREENINGS, ADVANCE CARE PLANNING, SAFE SITTER CLASSES, AND MORE. MEMORIAL HOSPITAL OF BOSCOBEL PART V, SECTION B, LINE 13H: GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINCS (GBAHC) UNDERSTANDS THAT NOT ALL PATIENTS ARE ABLE TO COMPLETE A FINANCIAL ASSISTANCE APPLICATION OR COMPLY WITH REQUESTS FOR DOCUMENTATION. THERE MAY BE INSTANCES UNDER WHICH A PATIENT'S QUALIFICATION FOR FINANCIAL ASSISTANCE IS ESTABLISHED WITHOUT COMPLETING THE FORMAL FINANCIAL ASSISTANCE APPLICATION. OTHER INFORMATION MAY BE UTILIZED BY GBAHC TO DETERMINE WHETHER A PATIENT'S ACCOUNT IS UNCOLLECTIBLE, AND THIS INFORMATION WILL BE USED TO DETERMINE PRESUMPTIVE ELIGIBILITY.PRESUMPTIVE ELIGIBILITY MAY BE GRANTED TO PATIENTS BASED ON THEIR ELIGIBILITY FOR OTHER PROGRAMS OR LIFE CIRCUMSTANCES SUCH AS:1. PATIENTS OR GUARANTORS WHO HAVE DECLARED BANKRUPTCY. IN CASES INVOLVING BANKRUPTCY, ONLY THE ACCOUNT BALANCE AS OF THE DATE THE BANKRUPTCY IS DISCHARGED WILL BE WRITTEN OFF.2. PATIENTS OR GUARANTORS WHO ARE DECEASED WITH NO ESTATE IN PROBATE.3. PATIENTS OR GUARANTORS DETERMINED TO BE HOMELESS.4. ACCOUNTS RETURNED BY THE COLLECTION AGENCY AS UNCOLLECTIBLE DUE TO ANY OF THE ABOVE REASONS.5. PATIENTS OR GUARANTORS WHO QUALIFY FOR STATE MEDICAID PROGRAMS, WILL BE ELIGIBLE FOR ASSISTANCE FOR ANY COST-SHARING OBLIGATIONS ASSOCIATED WITH THE PROGRAM OR UNCOVERED SERVICES.GBAHC UNDERSTANDS THAT CERTAIN PATIENTS MAY BE NON-RESPONSIVE TO GBAHC'S APPLICATION PROCESS. UNDER THESE CIRCUMSTANCES, GBAHC MAY UTILIZE OTHER SOURCES OF INFORMATION TO MAKE AN INDIVIDUAL ASSESSMENT OF FINANCIAL NEED. THIS INFORMATION WILL ENABLE GBAHC TO MAKE AN INFORMED DECISION ON THE FINANCIAL NEED OF NON- RESPONSIVE PATIENTS UTILIZING THE BEST ESTIMATES AVAILABLE IN THE ABSENCE OF INFORMATION PROVIDED DIRECTLY BY THE PATIENT.GBAHC MAY UTILIZE A THIRD-PARTY TO CONDUCT AN ELECTRONIC REVIEW OF PATIENT INFORMATION TO ASSESS FINANCIAL NEED. THIS REVIEW UTILIZES A HEALTHCARE INDUSTRY-RECOGNIZED MODEL THAT IS BASED ON PUBLIC RECORD DATABASES. THIS PREDICTIVE MODEL INCORPORATES PUBLIC RECORD DATA TO CALCULATE A SOCIO-ECONOMIC AND FINANCIAL CAPACITY SCORE THAT INCLUDES ESTIMATES FOR INCOME, ASSETS AND LIQUIDITY.THE ELECTRONIC TECHNOLOGY IS DESIGNED TO ASSESS EACH PATIENT TO THE SAME STANDARDS AND IS CALIBRATED AGAINST HISTORICAL APPROVALS FOR GBAHC FINANCIAL ASSISTANCE UNDER THE TRADITIONAL APPLICATION PROCESS.THE ELECTRONIC TECHNOLOGY, WHEN UTILIZED, WILL BE DEPLOYED PRIOR TO BAD DEBT ASSIGNMENT AFTER ALL OTHER ELIGIBILITY AND PAYMENT SOURCES HAVE BEEN EXHAUSTED. THIS ALLOWS GBAHC TO SCREEN ALL PATIENTS FOR FINANCIAL ASSISTANCE PRIOR TO PURSUING ANY EXTRAORDINARY COLLECTION ACTIONS. THE DATA RETURNED FROM THIS ELECTRONIC ELIGIBILITY REVIEW WILL CONSTITUTE ADEQUATE DOCUMENTATION OF FINANCIAL NEED UNDER THIS POLICY.WHEN ELECTRONIC ENROLLMENT IS USED AS THE BASIS FOR PRESUMPTIVE ELIGIBILITY, THE HIGHEST DISCOUNT LEVELS WILL BE GRANTED FOR ELIGIBLE SERVICES FOR RETROSPECTIVE DATES OF SERVICE ONLY. IF A PATIENT DOES NOT QUALIFY UNDER THE ELECTRONIC ENROLLMENT PROCESS, THE PATIENT MAY STILL BE CONSIDERED UNDER THE TRADITIONAL FINANCIAL ASSISTANCE APPLICATION PROCESS.PATIENT ACCOUNTS GRANTED PRESUMPTIVE ELIGIBILITY WILL BE RECLASSIFIED UNDER THE FINANCIAL ASSISTANCE POLICY. THEY WILL NOT BE SENT TO COLLECTION AND WILL NOT BE INCLUDED IN THE HOSPITAL'S BAD DEBT EXPENSE. PART V, SECTION B, LINE 7A: HTTP://WWW.GUNDERSENHEALTH.ORG/COMMUNITY-ASSESSMENT/ PART V, SECTION B, LINE 16A: HTTPS://WWW.GUNDERSENHEALTH.ORG/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE PART V, SECTION B, LINE 16B: HTTPS://WWW.GUNDERSENHEALTH.ORG/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE PART V, SECTION B, LINE 16C: HTTPS://WWW.GUNDERSENHEALTH.ORG/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE 3 1 - GUNDERSEN BOSCOBEL CLINIC 208 PARKER STREET BOSCOBEL WI 53805 PROVIDER BASED RURAL HEALTH CLINIC 2 - GUNDERSEN FENNIMORE CLINIC 220 LINCOLN AVENUE FENNIMORE WI 53809 PROVIDER BASED RURAL HEALTH CLINIC 3 - GUNDERSEN MUSCODA CLINIC 525 NORTH WISCONSIN AVENUE MUSCODA WI 53573 PROVIDER BASED RURAL HEALTH CLINIC PART I, LINE 3C: THE HOSPITAL USES THE FEDERAL POVERTY GUIDELINES AS ONE MEANS OF DETERMINING ELIGIBILITY FOR CHARITY CARE. THE FEDERAL POVERTY GUIDELINES ARE UPDATED AND PUBLISHED ANNUALLY BY THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. AS A GENERAL RULE, A PATIENT'S INCOME, BASED ON FAMILY SIZE, MUST BE AT OR BELOW 200% OF THE FEDERAL POVERTY GUIDELINES TO BE ELIGIBLE FOR THE CHARITY CARE PROGRAM. A SLIDING SCALE BASED ON THE PATIENT'S INCOME LEVEL UNDER THE FEDERAL POVERTY GUIDELINES WILL BE USED TO DETERMINE THE PRECISE AMOUNT OF CHARITY CARE FOR WHICH A PATIENT WILL BE ELIGIBLE. SOME PATIENTS MAY EXCEED 200% OF THE FEDERAL POVERTY GUIDELINES BUT MAY STILL BE ELIGIBLE FOR CHARITY CARE WHEN ADDITIONAL CRITERIA SUCH AS CATASTROPHIC MEDICAL COSTS ARE CONSIDERED. CATASTROPHIC MEDICAL CARE COSTS ARE DETERMINED ON A CASE-BY-CASE BASIS TO PATIENTS WHO DUE TO A SIGNIFICANT OR RECURRENCE OF MEDICAL BILLS MAY NEED ADDITIONAL COMMUNITY SUPPORT TO HELP A PATIENT OR THEIR FAMILY THROUGH A DIFFICULT TIME. PART I, LINE 7: THE COSTING METHOD USED ON FORM 990 IS BASED ON A COST-TO-CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST TO CHARGE RATIO IS APPLIED AGAINST VARIOUS REVENUE AND EXPENSE CATEGORIES TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER IRS SUGGESTED COSTING METHODS FOR THE FORM 990. THE COSTING METHODOLOGY FOR SUBSIDIZED HEALTH SERVICES IS BASED ON COST ALLOCATIONS FROM THE MEDICARE COST REPORT. THIS ALLOCATION METHOD AND PRINCIPLES OF ALLOCATION WERE USED TO DERIVE A SPECIFIC AMOUNT OF COST ALLOCATION TO THE VARIOUS PROGRAMS AND COST CENTERS OPERATED BY THE HOSPITAL. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES AT GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS INCLUDE THE OPERATION OF THE EMERGENCY DEPARTMENT AND THE OPERATION OF THREE RURAL HEALTH CLINICS. THE EMERGENCY DEPARTMENT IS STAFFED 24-HOURS PER DAY TO PROVIDE NEEDED ACCESS TO EMERGENCY CARE IN THE BOSCOBEL, WISCONSIN, COMMUNITY OR AS REQUIRED BY REGULATIONS TO BE ON-CALL AND AVAILABLE TO PROVIDE ACCESS TO EMERGENCY CARE AS A PART OF OPERATING A HOSPITAL IN THE STATE OF WISCONSIN. THE OPERATION OF THREE RURAL HEALTH CLINICS IS ALSO PROVIDED AS A SUBSIDIZED HEALTH SERVICE IN ORDER TO MEET HEALTH CARE NEEDS IN THE SURROUNDING COMMUNITIES. GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS CURRENTLY OPERATES RURAL HEALTH CLINICS IN BOSCOBEL, FENNIMORE, AND MUSCODA, WISCONSIN. IT IS THE GOAL OF THE HOSPITAL TO PROVIDE THESE SERVICES TO THE COMMUNITY REGARDLESS OF A PATIENT'S ABILITY TO PAY. PART II, COMMUNITY BUILDING ACTIVITIES: GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS PROVIDES SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFITS, AS DEFINED BY THE IRS, AND IN ADDITION, THE HOSPITAL BELIEVES THAT IT PROVIDES A CRITICALLY IMPORTANT BENEFIT WHICH IS NOT QUANTIFIED. GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS, LIKE MOST COMMUNITY HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY WHICH WITHOUT THE HOSPITAL, WOULD NOT BE AVAILABLE. BEYOND INPATIENT HOSPITALIZATIONS, THE HOSPITAL PROVIDES LOCAL ACCESS TO MANY SERVICES INCLUDING, BUT NOT LIMITED TO: DIAGNOSTICS, EMERGENCY SERVICES, INFUSION SERVICES, SWING BED SERVICES, CLINICAL SERVICES, LABORATORY SERVICES, REHABILITATION SERVICES, SPECIALTY MEDICINE, SPEECH PATHOLOGY, SURGICAL SERVICES, AND WOMEN'S SERVICES. PART III, LINE 2: THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST-TO-CHARGE RATIO, WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES EXCLUDING THE PROVISION FOR BAD DEBT, DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST-TO-CHARGE RATIO IS APPLIED AGAINST THE TOTAL CHARGES THAT ARE WRITTEN OFF DURING THE YEAR TO ESTIMATE THE COST OF CARE OF PATIENTS WHO HAVE ACCOUNTS THAT ARE DEEMED TO BE BAD DEBTS TO THE HOSPITAL. THE HOSPITAL ALSO RECOGNIZES THAT IT ALSO PROVIDES A DISCOUNT TO SELF-PAY OR UNINSURED PATIENTS. THESE AMOUNTS ARE EXCLUDED FROM GROSSPATIENT SERVICE REVENUE ON THE FINANCIAL STATEMENTS AND ARE NOT INCLUDED IN THE RATIO AS DESCRIBED ABOVE AND APPROVED BY THE IRS FOR USE ON FORM 990. IF CONSIDERED, THESE ADDITIONAL WRITE-OFF AMOUNTS TO UNINSURED ACCOUNTS WOULD ALSO INCREASE THE ESTIMATED BAD DEBT EXPENSE AMOUNT ASSOCIATED WITH THESE UNCOLLECTIBLE ACCOUNTS TO THE HOSPITAL. PART III, LINE 3: MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS 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 THE HOSPITAL HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND CREDIT TO ACCOUNTS RECEIVABLE. MANY TIMES, PATIENTS DO NOT COMPLETE THE REQUIRED CHARITY CARE APPLICATION AND ARE TRANSFERRED TO COLLECTION SERVICES EVEN THOUGH THE HOSPITAL PROVIDES THIS INFORMATION TO ALL PATIENTS AND ASSISTANCE WITH THE APPLICATIONS. DUE TO NO RESPONSES FROM SOME PATIENTS, A SIGNIFICANT AMOUNT OF BAD DEBTS COULD BE CONSIDERED AS CHARITY CARE. PART III, LINE 4: THE ORGANIZATION IS PART OF THE GUNDERSEN HEALTH SYSTEM'S CONSOLIDATED AUDIT IN WHICH THE FOOTNOTE THAT DISCUSSES THE BAD DEBT (IMPLICIT PRICE CONCESSIONS) EXPENSE IS LOCATED IN FOOTNOTE #2, PAGES 10, 11, 18 AND 19. PART III, LINE 8: THE TOTAL MEDICARE REVENUE SHOWN IN SCHEDULE H OF THE FORM 990 IS BASED ON THE IRS 990 INSTRUCTIONS AND INCLUDES ONLY A PORTION OF THE GROSS MEDICARE REVENUE OF THE HOSPITAL, AND ALSO DOES NOT CONSIDER ALL CONTRACTUAL ADJUSTMENTS FOR SERVICES REIMBURSED BY THE MEDICARE PROGRAM. AMOUNTS LISTED FOR MEDICARE REVENUES DO NOT INCLUDE PHYSICIAN SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT THE HOSPITAL AS WELL AS HOSPITAL INPATIENT PHYSICIAN PROFESSIONAL SERVICES, RESPIRATORY THERAPY PROFESSIONAL SERVICES, RADIOLOGIST PROFESSIONAL SERVICES, SURGEON PROFESSIONAL SERVICES, AND REVENUES FOR ANY PATIENTS COVERED UNDER MEDICARE ADVANTAGE PLAN PROGRAMS. PHYSICIAN PROFESSIONAL SERVICES ARE REIMBURSED PRIMARILY ON FEE SCHEDULE REIMBURSEMENTS AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY AND PHYSICIAN SERVICES PROVIDED TO MEDICARE PATIENTS ARE VITAL TO THE WELL-BEING OF THE COMMUNITY AND AS SUCH THESE COSTS AND SHORTFALLS SHOULD ALSO BE CONSIDERED AS AN ADDITIONAL BENEFIT THAT GUNDERSEN BOSCOBEL HOSPITAL AND CLINICS PROVIDES TO THE COMMUNITY AND SURROUNDING AREAS. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON THE FILED MEDICARE COST REPORT FOR THE PERIOD ENDED DECEMBER 31, 2021 AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES, AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUE (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE). WHETHER THERE IS A SHORTFALL OR SURPLUS ON SERVICES PROVIDED TO MEDICARE MEMORIAL HOSPITAL OF BOSCOBEL 39-0845590 BENEFICIARIES, THESE PEOPLE, WHO ARE TYPICALLY ELDERLY OR DISABLED MEMBERS OF THE COMMUNITY, ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. PART III, LINE 9B: UNDER THE HOSPITAL'S COLLECTION AND CHARITY CARE POLICIES, GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS MAKES EVERY ATTEMPT TO IDENTIFY AND PROMOTE CHARITY CARE TO PATIENTS. INCLUDED IN THE HOSPITAL'S CHARITY CARE POLICY IT IS NOTED THAT PATIENTS MAY QUALIFY FOR CHARITY CARE EITHER PRIOR TO ADMISSION OR FOLLOWING DISCHARGE. ALL INPATIENT SELF-PAY ADMISSIONS ARE SCREENED BY THE HOSPITAL'S PATIENT FINANCIAL COUNSELOR OR SOCIAL WORKERS TO ALLOW THESE PATIENTS THE ABILITY TO COMPLETE THEIR APPLICATION DURING THEIR STAY AT THE HOSPITAL, DEPENDING UPON THE PATIENT'S CONDITION, OR THE PATIENT'S RESPONSIBLE PARTY MAY BE CONTACTED TO COMPLETE AND RETURN THE FORMS AT A LATER TIME WHEN THEIR CARE ALLOWS THIS COMPLETION. DURING THE PATIENT ACCOUNT COLLECTION PROCESS, SELF-PAY PATIENTS ARE ALSO INFORMED OF THE HOSPITAL'S COLLECTION POLICIES AS WELL AS THE CHARITY CARE PROGRAM TO ALLOW PATIENTS THE OPPORTUNITY TO COMPLETE THE APPROPRIATE FORMS AND QUALIFY UNDER THE PROGRAM. PART VI, LINE 2: GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITIES AND AREAS IT SERVES BY REVIEWING LOCAL DEMOGRAPHICS AND TRENDS IN PATIENT SERVICE UTILIZATION TO DETERMINE WHICH SERVICES COULD AND SHOULD BE MADE AVAILABLE TO THE COMMUNITY IN A COST-EFFECTIVE MANNER TO BE CONSISTENT WITH THE HOSPITAL'S MISSION IN THE COMMUNITY. GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS ALSO REVIEWS STATISTICS IN THE HOSPITAL, CLINIC, AND OTHER ORGANIZATIONAL DEPARTMENTS TO REVIEW THE CURRENT SERVICES BEING OFFERED AND ENSURE THAT RESOURCES ARE BEING APPROPRIATELY ALLOCATED TO AREAS IN NEED BY COMMUNITY MEMBERS AND PATIENTS. THE HOSPITAL ALSO MEETS WITH LOCAL COMMUNITY MEMBERS AND ITS PHYSICIAN GROUP TO DETERMINE WHICH SERVICES MAY BENEFIT THE COMMUNITY. DURING FISCAL YEAR 2021, THE HOSPITAL COLLABORATED WITH OTHER AREA HOSPITALS TO COMPLETE A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA). THROUGH THE CHNA PROCESS THE HOSPITAL CONSIDERED, COUNTY HEALTH STATISTICS, MEDICAL RESOURCES, SAFETY FACTORS, SOCIO-ECONOMIC INDICATORS, TRANSPORTATION ISSUES, ACCESS TO RESOURCES, AND ENVIRONMENTAL QUALITY. PART VI, LINE 3: PATIENTS IN NEED OF FINANCIAL ASSISTANCE CAN MEET WITH THE HOSPITAL'S FINANCIAL COUNSELOR EITHER AT THE TIME SERVICE IS PROVIDED OR WHEN THE PATIENT'S BILL IS GENERATED. THE FINANCIAL COUNSELOR EXPLAINS THE VARIOUS PAYMENT OPTIONS AVAILABLE TO THE PATIENT AS WELL AS THE HOSPITAL'S CHARITY CARE PROGRAM AND OFFERS THE CHARITY CARE APPLICATION WHEN APPROPRIATE. IF OTHER PROGRAMS ARE AVAILABLE TO THE PATIENT, SUCH AS THE WISCONSIN MEDICAID OR BADGERCARE PROGRAMS, THESE PATIENTS ARE REFERRED TO THE APPROPRIATE GOVERNMENT AGENCY FOR FURTHER ASSISTANCE. THE HOSPITAL ALSO PROVIDES CERTIFIED APPLICATION COUNSELORS FOR ASSISTING PATIENTS WITH OBTAINING COVERAGE THROUGH THE HEALTH INSURANCE MARKETPLACE. PART VI, LINE 4: THE PRIMARY SERVICE AREA FOR GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS ENCOMPASSES ALL PERSONS LIVING WITHIN A 20 TO 30 MILE RADIUS OF THE HOSPITAL. THE HOSPITAL ALSO DETERMINED THAT PRIMARY CLINICAL HEALTH CARE WAS A NEEDED SERVICE IN TWO SURROUNDING COMMUNITIES, SO THE HOSPITAL ALSO OPERATES PROVIDER-BASED RURAL HEALTH CLINICS IN FENNIMORE AND MUSCODA, WISCONSIN. PART VI, LINE 5: GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS OFFERS HEALTH SCREENINGS, EDUCATIONAL DISPLAYS, AND PRESENTATIONS ON A VARIETY OF TOPICS SUCH AS HEALTHY EATING, EXERCISE, HEART HEALTH, CHOLESTEROL, ETC. TO MEMBERS OF THE COMMUNITY. PROGRAMS AND SERVICES ARE ALSO CONSIDERED BY THE HOSPITAL'S BOARD OF DIRECTORS, WHICH INCLUDES FIVE LOCAL COMMUNITY MEMBERS WHO RESIDE WITHIN A THIRTY-MILE RADIUS OF THE HOSPITAL. THE HOSPITAL ALSO CONSIDERS A RELATIVELY OPEN MEDICAL STAFF POLICY ALLOWING PROPERLY CREDENTIALED PROVIDERS THE ABILITY TO PRACTICE MEDICINE AND FOLLOW-UP WITH PATIENTS UTILIZING THE HOSPITAL'S FACILITIES. PART VI, LINE 6: GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS IS AFFILIATED WITH GUNDERSEN HEALTH SYSTEM. THIS AFFILIATION PROVIDES LOCAL SERVICES IN CARDIOLOGY, NEUROLOGY, PODIATRY, DERMATOLOGY, UROLOGY, GYNECOLOGY, ENDOCRINOLOGY, HEMATOLOGY/ONCOLOGY, AND VASCULAR MEDICINE AS WELL AS LAPAROSCOPIC AND ORTHOPEDIC SURGERY. PART VI, LINE 7, REPORTS FILED WITH STATES WI 0 0 0 0 0 0 0 0 0 MARILU BINTZ MD BOARD MEMBER/MED VP GHS 0 532663 0 58268 0 29831 0 44225 0 40101 0 705088 0 0 KRAIG SCHUSTER BOARD MEMBER/VP GHS 0 241057 0 38595 0 4517 0 40632 0 40556 0 365357 0 0 ANDY NAHAS VICE PRESIDENT/GHS OPTOMETRIST 0 188393 0 27137 0 12936 0 33783 0 26150 0 288399 0 0 THERESA BRAUDT ADMINISTRATOR 0 156640 0 20537 0 4023 0 26361 0 36729 0 244290 0 0 JAMES KLOCK BOARD MEMBER/DIR OF REG IS 0 136612 0 26294 0 238 0 24127 0 33100 0 220371 0 0 ALAN EBER BOARD MEMBER/DIR OF BUS. SERV. 0 132438 0 14379 0 184 0 21663 0 33324 0 201988 0 0 KEITH FRYE SECRETARY/ADMIN DIR - LAB 0 117862 0 28119 0 400 0 21526 0 30577 0 198484 0 0 TARA WOOD PHARMACIST 131471 0 29421 0 0 0 6708 0 23705 0 191305 0 0 0 JENNIFER BOIGENZAHN FINANCE ADMINISTRATOR 0 120013 0 18495 0 2475 0 19960 0 11255 0 172198 0 0 DAWN THORSTEN BOARD MEMBER/QUALITY DIRECTOR 0 106381 0 10084 0 1870 0 17946 0 34595 0 170876 0 0 LISA WITTER PHARMACIST 115137 0 10230 0 1170 0 5308 0 22904 0 154749 0 0 0 SCHEDULE J, PART 1, LINE 3 A RELATED ORGANIZATION OF THE FILING ORGANIZATION USES ONE OR MORE OF THE FOLLOWING TO ESTABLISH THE COMPENSATION OF THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL: -COMPENSATION COMMITTEE -INDEPENDENT COMPENSATION CONSULTANT -COMPENSATION SURVEY OR STUDY, AND -APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE PLEASE REFER TO THE FORM 990, PART VI, LINE 15A DISCLOSURE IN SCHEDULE O FOR ADDITIONAL DETAILS ON HOW COMPENSATION OF THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL IS ESTABLISHED. FORM 990, PART VI, SECTION A, LINE 4 GUNDERSEN AND BELLIN HEALTH SYSTEMS, INC. (BELLIN), EACH A WISCONSIN NONPROFIT, NON-STOCK CORPORATION, ENTERED INTO A COMBINATION AGREEMENT DATED JULY 29, 2022 (THE AGREEMENT), TO ALIGN THEIR RESPECTIVE OPERATIONS AND TO FORM A SINGLE NONPROFIT HEALTH SYSTEM THROUGH THE CREATION OF BELLIN GUNDERSEN HEALTH SYSTEM, INC., A WISCONSIN NONPROFIT, NON-STOCK CORPORATION (BELLIN GUNDERSEN). ON DECEMBER 1, 2022, UPON CONSUMMATION OF THE ALIGNMENT OF THE TWO SYSTEMS (THE AFFILIATION), BELLIN GUNDERSEN BECAME THE SOLE CORPORATE MEMBER OF BOTH BELLIN AND GUNDERSEN. BELLIN AND GUNDERSEN AND THEIR RESPECTIVE AFFILIATES ARE EXPECTED TO MAINTAIN THEIR RESPECTIVE CORPORATE EXISTENCE. IN DECEMBER 2022, THE BYLAWS OF GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. WERE AMENDED AND RESTATED TO UPDATE THE SOLE CORPORATE MEMBER TO BELLIN GUNDERSEN HEALTH SYSTEM, INC. THE BYLAWS WERE ALSO UPDATED TO SPECIFY THE POWERS RETAINED BY GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. THE CHIEF EXECUTIVE OFFICER OF BELLIN GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. RETAINS AUTHORITY TO APPROVE ANY SIGNIFICANT CHANGES TO THE CORPORATION. SUBJECT TO THE RESERVED POWERS SPECIFIED IN THE BYLAWS, THE AFFAIRS OF THE CORPORATION SHALL BE MANAGED BY ITS BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 6 THE ARTICLES OF INCORPORATION OF GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS PROVIDES FOR ONE MEMBER OF THE CORPORATION. THE SOLE CORPORATE MEMBER OF GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS IS GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. FORM 990, PART VI, SECTION A, LINE 7A AS THE SOLE CORPORATE MEMBER AND UNDER THE TERMS OF THE AFFILIATION AGREEMENT, GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. MAY APPOINT, REMOVE, OR ELECT CERTAIN OFFICERS AND/OR MEMBERS OF THE BOARD OF DIRECTORS OF GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS. GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. MAY APPOINT SIX MEMBERS OF THE BOARD OF DIRECTORS OF GUNDERSEN BOSCOBEL AREA HOSPITAL AND CLINICS. FORM 990, PART VI, SECTION A, LINE 7B THE SOLE MEMBER, GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. HAS THE FOLLOWING RESERVE RIGHTS OF APPROVAL: THE INCURRENCE OF DEBT (OTHER THAN DEBT INCURRED FOR THE ACQUISITION OF GOODS THAT ARE ACQUIRED IN THE ORDINARY COURSE OF BUSINESS OR DEBT INCLUDED IN APPROVED BUDGETS) AND THE GRANT OF ANY SECURITY INTEREST, PLACE ANY ENCUMBRANCES, ENTER INTO ANY COVENANTS, AND DIRECT EXECUTION OF ANY DOCUMENTS AND THE TAKING OF ANY ACTIONS NECESSARY OR APPROPRIATE IN CONNECTION WITH THE INCURRENCE OF SUCH DEBT: AND THE ANNUAL OPERATING BUDGET AND CAPITAL EXPENDITURES. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM AND THEN REVIEWED BY THE ORGANIZATION'S MANAGEMENT. A FINAL COPY OF THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF DIRECTORS DISCLOSES ANY CONFLICTS OF INTEREST BY COMPLETING A QUESTIONNAIRE AND DISCLOSURE FORM ANNUALLY. EMPLOYEES ARE REQUIRED TO REVIEW THE CONFLICT OF INTEREST POLICY UPON HIRE AND AT ANNUAL INTERVALS. IF ANY SIGNIFICANT CONFLICTS ARISE WITH MEMBERS OF THE BOARD OF DIRECTORS, MANAGEMENT, OR KEY EMPLOYEES, IT IS PROPERLY DOCUMENTED AND FOLLOWED UP ON BY THE APPROPRIATE GOVERNING GROUP OR DEPARTMENT WITHIN THE ORGANIZATION ACCORDING TO THE CONFLICT OF INTEREST POLICY. FORM 990, PART VI, SECTION B, LINE 15 FOR THE PURPOSES OF DETERMINING COMPENSATION, GUNDERSEN AREA BOSCOBEL HOSPITAL AND CLINICS RELIED ON ITS AFFILIATED ORGANIZATION, GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES, INC., TO ESTABLISH COMPENSATION OF THE CEO, CFO, AND OTHER OFFICERS. GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES, INC. USED THE FOLLOWING PRACTICES FOR ESTABLISHING COMPENSATION FOR SUCH INDIVIDUALS: COMPENSATION SURVEY OR STUDY, COMPENSATION COMMITTEE, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. FORM 990, PART VI, SECTION C, LINE 19 THE ABBREVIATED FINANCIAL STATEMENTS ARE MADE PUBLICLY AVAILABLE THROUGH THE WISCONSIN HOSPITAL ASSOCIATION AND THE COMPLETE AUDITED FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. GOVERNING DOCUMENTS AND THE CONFLICT OF INTEREST POLICY ARE ALSO AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VII, LINE 1A, EXPLANATION OF HOURS WORKED: SOME OFFICERS AND BOARD MEMBERS ARE EMPLOYED BY GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. AND ITS AFFILIATES. GUNDERSEN LUTHERAN HEALTH SYSTEM, INC.'S PURPOSE IS TO SERVE AS A SUPPORTING ORGANIZATION TO MULTIPLE SUBSIDIARY ORGANIZATIONS AS LISTED IN SCHEDULE R AND THESE OFFICERS AND BOARD MEMBERS OFTEN WORK IN EXCESS OF 40 HOURS PER WEEK PROVIDING SERVICES TO AFFILIATED ORGANIZATIONS. THESE HOURS ARE REFLECTED IN LINE 2 OF COLUMN B. FORM 990, PART IX, LINE 11G ADMINISTRATIVE/MANAGEMENT FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 97,598. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 97,598. ER PHYSICIAN COVERAGE: PROGRAM SERVICE EXPENSES 2,491,591. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,491,591. INFORMATION SYSTEMS PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 32,813. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 32,813. LAB SERVICES: PROGRAM SERVICE EXPENSES 446,087. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 446,087. OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 333,281. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 333,281. RADIOLOGY PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,767,424. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,767,424. SPECIALITY SERVICES: PROGRAM SERVICE EXPENSES 542,316. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 542,316. SURGICAL SERVICES: PROGRAM SERVICE EXPENSES 592,588. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 592,588. FORM 990, PART XI, LINE 9: NET CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION -199,621. 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