Complicance Check Questionnaire/Tax Exempt Hospitals

COMPLIANCE CHECK QUESTIONNAIRE

TAX-EXEMPT HOSPITALS

This questionnaire asks for information about your hospital and how it operates. Answer the questions based on your hospital’s most recently completed tax period. If additional space is needed, attach additional sheets. Please complete the questionnaire and follow the instructions in the letter for returning the information to us.

PART I – ORGANIZATION

Name of Hospital:

EIN:

Most Recently Completed Tax Period:

PART II – OPERATIONS

1. Please indicate the category below that best described your hospital or the type of service it provided to the majority of admissions. Check only one box.

	General medical and surgical		Obstetrics and gynecology
	Hospital unit of an institution (prison, college etc)		Eye, ear, nose and throat
	Hospital unit within an institution for the mentally retarded		Rehabilitation
	Surgical		Orthopedic
	Psychiatric		Chronic disease
	Tuberculosis and other respiratory diseases		Institution for the mentally retarded
	Cancer		Acute long-term care
	Heart		Other – Specify:
	Alcoholism and other chemical dependency
	Organization is not a §501(c)(3) hospital. If you checked this box, stop here and return the questionnaire to us.

Patients

2. What were the total number of:

inpatients?

outpatients?

emergency room patients?

3. How many had private insurance?

inpatients?

outpatients?

emergency room patients?

4. How many had Medicare?

inpatients?

outpatients?

emergency room patients?

5. How many had Medicaid?

inpatients?

outpatients?

emergency room patients?

6. How many had other public insurance?

inpatients?

outpatients?

emergency room patients?

7. How many had no insurance?

inpatients?

outpatients?

emergency room patients?

8. Did your hospital deny medical services to any individuals with:

1. private insurance? Yes No

If yes, please explain.

2. Medicare? Yes No

If yes, please explain.

3. Medicaid? Yes No

If yes, please explain.

4. other public health insurance? Yes No

If yes, please explain.

5. no insurance? Yes No

If yes, please explain.

Emergency Room

9. Did your hospital operate an emergency room? Yes No

If no, please explain.

10. What were the emergency room’s hours of operation?

24 hours a day, 365 days a year

	Other, please explain.

11. Did your hospital’s emergency room have a trauma center? Yes No

12. If yes, what was the trauma center’s level of certification?

	Level I
	Level II
	Level III
	Level IV
	Other, please describe.

13. Did your hospital’s emergency room provide services to all members of the community regardless of their ability to pay? Yes No

If no, please explain.

14. Did your hospital’s emergency room deny services to any individuals that requested such services?
    Yes No

If yes, please explain.

Board of Directors

15. How many directors were on your hospital’s board? ______

16. What was the professional background of each director? Please indicate the number of directors in each category listed below.

	Accounting		Government		Philanthropy
	Banking/Finance		Insurance		Public/Elected Official
	Business		Law		Religion
	Community Service		Management		Retail
	Education/Academia		Manufacturing		Social Services
	Fine Arts		Medicine/Health Care		Other (specify)

17. How often did the board of directors meet?

Monthly

Quarterly

Annually

Other, please describe _______________________________________________

18. On average, how many of the directors were present at each meeting? _______

Medical Staff Privileges

19. Were all qualified physicians in your community eligible for medical staff privileges at your hospital?
    Yes No

If no, please explain.

20. Have you denied any qualified physician’s application for medical staff privileges?
    Yes No

If yes, please explain.

Medical Research

21. Did your hospital conduct any medical research programs? Yes No

If yes, please answer questions 22 through 24. If no, go to question 25.

22. How much did your hospital spend on medical research programs? $___________

23. How much of your hospital’s funding for medical research came from:

1. public sources (for example, government grants)? $__________

2. private sources (for example, contracts with for-profit corporations)? $__________

24. Did your hospital limit public access to the findings or results from any of its medical research programs? Yes No

If yes, please explain.

24. How much did your hospital provide in grants to individuals or organizations to fund medical research programs? $____________

24. Was public access limited to the findings or results from any medical research programs for which your hospital provided grants? Yes No

If yes, please explain.

24. Did your hospital conduct any medical trial studies? Yes No

If yes, answer questions 28 and 29. If no, go to question 30.

24. How much of your hospital’s funding for medical trial studies came from:

1. public sources (for example, government grants)? $____________

2. private sources (for example, contracts with for-profit corporations)? $____________

24. Did your hospital limit public access to the findings or results from any of its medical trial studies?
    Yes No

If yes, please explain.

Professional Medical Education and Training

24. Did your hospital conduct any professional medical education and training programs?
    Yes No

If yes, answer questions 31 and 32. If no, go to question 33.

24. How much did your hospital spend on professional medical education and training programs? $____________

24. How much of your funding for professional medical education and training came from:

1. public sources (for example, government grants)? $_____________

2. private sources (for example, contracts with for-profit corporations)? $_____________

24. Did your hospital provide grants to individuals or organizations to fund professional medical education and training programs? Yes No

If yes, how much did it spend? $___________

Uncompensated Care

24. Did your hospital have a written policy stating the circumstances under which it would provide uncompensated care? Yes No

Please explain.

24. How many individuals received uncompensated care from your hospital? __________

24. How much did your hospital spend on uncompensated care? $_______________

24. Did your hospital treat as uncompensated care the excess of what it charged for services and the amount:

1. private insurance paid or allowed for such services (including any patient co-payments and deductibles)? Yes No

If yes, please explain.

2. Medicare paid or allowed for such services (including any patient co-payments and deductibles)?
   Yes No

If yes, please explain.

3. Medicaid paid or allowed for such services (including any patient co-payments and deductibles)?
   Yes No

If yes, please explain.

4. other public insurance paid or allowed for such services (including any patient co-payments and deductibles)? Yes No

If yes, please explain.

5. individuals without insurance paid your hospital for such services?

Yes No

Please explain.

24. Did your hospital treat bad debts as uncompensated care? Yes No

Please explain.

24. Did your hospital treat any other items or costs as uncompensated care? Yes No

If yes, please explain.

24. Did your hospital report its expenditures for uncompensated care to a state government?
    Yes No

If yes, what amount did it report?

$

24. Did your hospital provide:

1. inpatient services to any individual without compensation? Yes No

If yes, please describe your policy.

2. outpatient services to any individual without compensation? Yes No

If yes, please describe your policy.

3. emergency room services to any individual without compensation?
   Yes No

If yes, please describe your policy.

24. If you answered yes to 41 a, b, or c, indicate below, for each category of patient, when your hospital determined that it would provide services to an individual without compensation? Check all that apply.

	At or before providing services	Less than 30 days after providing services	30 to 90 days after providing services	More than 90 days after providing services	When insurance denied all or part of claim	Other (explain below)
Impatient
Outpatient
Emergency Room

If you checked the other box, please describe

Billing Practices

24. Did your hospital require all individuals to pay, or make arrangements to pay, prior to, or at the time it provided:

1. inpatient services? Yes No

2. outpatient services? Yes No

3. emergency room services? Yes No

24. In the space provided below, please explain your payment policies for:

inpatients
outpatients

emergency room patients

24. How many days after your hospital provided services did it send the patient a bill? ___________

24. How many days after the billing date did the patient have to pay for services? __________

24. If a patient failed to pay for services, how many notices did your hospital send before it began collection actions? __________

24. Did your hospital refer all past due bills to collection agencies? Yes No

24. Did your hospital enter into installment agreements or other extended payment arrangements with patients who were unable to pay? Yes No

24. Please describe the circumstances in which you would enter into installment agreements or other extended payment arrangements with patients who were unable to pay.

24. How many days after a patient had not paid all or part of a bill did your hospital classify it as a bad debt? __________

24. Did your hospital charge all patients the same price for the same services? Yes No

If yes, go to question 57. If no, answer questions 53-56.

24. Did your hospital charge patients with private insurance higher prices for hospital services than patients with public insurance (including Medicare and Medicaid)? Yes No

Please explain.

24. Did your hospital charge patients with no insurance higher prices for hospital services than patients with public insurance (including Medicare and Medicaid)? Yes No

Please explain.

24. Did your hospital charge patients with no insurance higher prices for hospital services than patients with private insurance? Yes No

Please explain.

24. Did your hospital charge individuals different prices for hospital services based on their income, assets or ability to pay for such services? Yes No

Please explain.

Community Programs

24. Did your hospital provide medical screening programs for the community? Yes No

If yes, answer questions 58 through 60. If no, go to question 61.

24. How much did your hospital spend on medical screening programs for the community? $___________

24. Were all members of the community eligible for your hospital’s medical screening programs?
    Yes No

If no, please explain.

24. Did the hospital charge a fee for any community medical screening programs? Yes No

If yes, please explain.

24. Did your hospital provide immunization programs for the community? Yes No

If yes, answer questions 62 through 64. If no, go to question 65.

24. How much did your hospital spend on immunization programs for the community? $__________

24. Were all members of the community eligible for your hospital’s immunization programs?
    Yes No

If no, please explain.

24. Did your hospital charge a fee for its community immunization programs? Yes No

If yes, please explain.

24. Did your hospital provide any lectures, seminars or other educational programs for the community?
    Yes No

If yes, answer questions 66 through 68. If no, go to question 69.

24. How much did your hospital spend on lectures, seminars and other educational programs for the community? $___________

24. Were all members of the community eligible for your hospital’s community educational programs?
    Yes No

If no, please explain.

24. Did your hospital charge a fee for its community education programs? Yes No

If yes, please explain.

24. Did your hospital conduct studies on the unmet health care needs of the community?
    Yes No

If yes, how much did your hospital spend on these studies? $___________

24. Did your hospital have programs to improve access to health care for individuals who lacked insurance? Yes No

If yes, how much did your hospital spend on these programs? $____________

24. Did your hospital produce or distribute newsletters or publications that provided information to the community on health care issues? Yes No

If yes, how much did your hospital spend on these newsletters or publications? $_____________

24. Did your hospital have any other programs or activities that promoted health for the benefit of the community? Yes No

If yes, please explain and indicate how much was spent on these programs and activities.

PART III – COMPENSATION PRACTICES

Please answer the questions in this part as it pertains to employees in your hospital who are disqualified persons within the meaning of Internal Revenue Code (IRC) Section 4958(f)(1).

1. Please provide the names and titles of your hospital’s officers, directors, trustees and key employees and amounts of salary and other compensation paid by your hospital to such officers, directors, trustees and key employees. Add additional sheets if necessary.

Name	Title	Salary1	Other Compensation2
1 Salary includes all forms of cash and non-cash compensation received whether paid currently or deferred.   2 Other Compensation includes contributions to employee benefit plans and deferred compensation plans, and expense allowances from non-accountable plans.

2. Did your hospital have a formal written compensation policy? Yes No

3. Was compensation approved, in advance, by individuals that did not have a conflict of interest with the compensation arrangement being approved? Yes No

4. Who in your hospital set the compensation for officers, directors, trustees, and key employees? Check all that apply.

Officers

Board of Directors

Compensation Committee

Other – Please explain:________________________________________________________

5. Please check any of the following that your hospital used to determine compensation amounts:

Published surveys of compensation at similar institutions;

Internet research on compensation at similar institutions conducted by your employees;

Phone survey(s) of compensation at similar institutions conducted by your hospital’s employees;

Outside expert report prepared specifically for your hospital by an expert employed by your hospital for this purpose;

Outside expert report prepared by an expert employed by an unrelated organization;

Written offers of employment from similar institutions; and

Other – Describe:___________________________________________________________

6. Please check the appropriate boxes, in the following chart, regarding factors included in the comparability data used by your hospital:

comparability factors:	Yes	no	Was factor checked used for all § 4958(f)(4) employees? *
			Yes	No*
Level of Employee Education and Experience
Specific Responsibilities of Position
Same Geographic or Metropolitan Area
Services of a Similar Nature Provided
Similar Number of Beds, Admissions, or Outpatient Visits
Other Factors. Please explain.

*If no, please explain.

7. Did your hospital’s comparability data include information from other tax-exempt hospitals?
   Yes No

If no, please explain.

7. Was your hospital’s actual compensation set within the range of comparability data?
   Yes No

If no, please explain.

7. Did your hospital have a business relationship with any of its officers, directors, trustees or key employees other than through their position as officers, directors, trustees, or key employees?
   Yes No

If yes, identify the individuals and describe the business relationship below.

Name	Title	Description of Business Relationship

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. We need it to ensure that you are complying with these laws.

The IRS may not conduct or sponsor, and an organization is not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB number. Books or records relating to a collection of information must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and tax return information are confidential, as required by 26 U.S.C. 6103 and 6104.

13