Presentation Explores Many Contexts of Community Benefit

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PYA Principal David McMillan gets to the bottom of the definition of community benefit in “Community Benefit: One Term, Many Contexts,” a presentation given at the 2013 AICPA Healthcare Industry Conference.

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  • The Community Benefit Standard was set out in 1969 in a revenue ruling (Rev. Rul. 69-545).
  • The community benefit standard is the center of what concerns people about non-profit hospitals, including the cost and delivery of care and the treatment of patients when it comes to billing and collection. To some, community benefit should be narrowly interpreted to equate with charity care; to others; it should be broadly construed to encompass virtually everything a non-profit hospital does. And there are still others that believe it fits somewhere in the midst of these competing interpretations.
  • Hospitals are a bit different from other charities. We ordinarily expect a charity to provide for a charitable class of people – a prime example is providing food, clothing and shelter to the poor or distressed. This is not necessarily the standard for a nonprofit hospital. Instead, the non-profit hospital is required to show it benefits the community it serves through the promotion of health in its community. Thus, in determining community benefit, the hospital may include services provided to persons commonly thought of as being outside the traditional definition of a charitable class – the poor or distressed.
  • So what does “community benefit” mean? We have to understand it in context. Non-profit hospitals operate alongside for-profit counterparts in many parts of the country. To the man on the street, a tax-exempt hospital may look remarkably similar to one that pays tax. And that same man on the street might reasonably ask why the standard discussed previously – that the hospital benefits the community it serves through the promotion of health – would not also be met by a for-profit hospital. So the tax policy and tax administration question that needs to be addressed is: How does one meaningfully differentiate a tax-paying, for-profit hospital from a non-profit hospital that enjoys exemption from federal and state tax, exemption from property tax, and eligibility for favorable bond financing? That is where the community benefit standard comes in – to help one make the distinction.
  • It may be somewhat surprising to learn that neither the Internal Revenue Code nor the underlying regulations explicitly provides for the exemption for non-profit hospitals from federal income taxation. Nonetheless, we have long recognized that hospitals may qualify for exemption under Section 501(c)(3). To qualify as an organization described in Section 501(c)(3), a hospital must demonstrate that it provides benefits to a class of persons broad enough to benefit the community, and it must show that it is operated to serve a public rather than a private interest. In a nutshell, that is the standard – a hospital must show that it benefits the public by promoting the health of that community. The community benefit standard looks at five factors.
  • The five factors are not the only factors. It is a facts and circumstances determination, with no one factor controlling. The 1969 ruling also modified (but left in place) an earlier revenue ruling that based exemption on providing charity care.
  • The health care industry has changed since 1969. Medicare and Medicaid now reimburse hospitals for medical care for the elderly and the indigent. Hospitals that participate in Medicare and have an emergency room are generally required – for reasons unrelated to the community benefit standard (EMTALA) – to treat any patient in an emergency condition, regardless of ability to pay.
  • Provena Covenant Medical Center is a 254 bed non-profit hospital in Urbana, IL. In 2002, the Champaign County Board of Review challenged Provena Covenant's tax-exempt status based on debt-collection tactics and amount of charity care offered. Ultimately, the Illinois Department of Revenue denied Provena Covenant's status, which led to the matter to be considered by the circuit court of Sangamon County, IL, which sided with Provena Covenant. The matter was then considered by the Appellate Court, and later, the Illinois Supreme Court which both rendered decisions against Provena Covenant's tax-exempt status. In a March 18, 2010 judgment by the Illinois Supreme Court, the Court agreed that the Department of Revenue had acted properly in denying charitable and religious property tax exemptions requested by Provena Hospitals. In the judgment, the Court noted that “a mere 302 of its (Provena Covenant's) 110,000 admissions received reductions in their bills based on charitable considerations.” The court added, “uninsured patients were charged PCMC’s “established” rates, which were more than double the actual costs of care. When patients were granted discounts at the 25 and 50 percent levels, the hospital was therefore still able to generate a surplus.” In response, the head of Provena Covenant Medical Center said, “We are deeply disappointed that the Illinois Supreme Court has denied the property tax exemption of Provena Covenant Medical Center,” said Jon Sokolski, Chair of the Board. “Provena…cares for all in our community who need our health services regardless of their ability to pay. In 2008, we provided more than $38 million in free care and other community benefits.”It increasingly appears that federal tax exemption is no longer always dispositive of how a state or local government will regard a hospital.
  • The House Ways and Means Committee also expressed interest in this issue. In July 2005, then-Chairman Thomas convened a hearing on tax-exempt hospitals and healthcare organizations, and the IRS’s administration of the area. He followed this in December, 2006 with proposed legislation requiring non-profit hospitals to provide a minimum level of charity care to individuals with incomes below the federal poverty limit, and limiting payments to the “average insured rate” for individuals with incomes less than two times the federal poverty limit. Sanctions would have included an excise tax on hospitals and the disallowance of charitable deductions to contributors.
  • The Form 990, Return of Organization Exempt from Income Tax, was completely redesigned for 2008. One of the goals of the redesign was to use the new 990 to contribute to the review of the community benefit standard. The IRS believed: better data would allow the public, the Congress, the IRS, the States, and other stakeholders to make better-informed decisions about this area. As part of the 990 redesign, the IRS added a new hospital schedule – the Schedule H – that requires non-profit hospitals to report community benefit and other information about themselves.The Schedule H addresses the “what,” the “how,” and the “by whom” aspects of community benefit, but it does not answer all questions pertinent to the debate. There remain some key areas where consensus does not yet exist (such as bad debt).
  • The quantifiable community benefit identified by hospitals is reported according to specific instructions outlined by the following: Internal Revenue Service, Centers for Medicare & Medicaid Services and Generally Accepted Accounting Principles.
  • Community Benefit, in the form of charity care, is reported to the Federal Government (and to the public) on each of the forms above. Though the terms the are the same, the definitions and therefore the resulting amounts, differ. Form 990 is a public document. It is available for viewing on GuideStar.org and must be provided by the organization upon request. The Medicare cost report is also a public document and may be requested from a Medicare contractor under the Freedom of Information Act.
  • Differences in charity care amounts reported on the forms above are attributable to:Variances in the manner in which charity care is defined; andTiming inconsistencies resulting from the varying filing requirements for each of the forms.
  • This is a summary of the “chart” at the bottom of Schedule H, page 1.
  • The Cost report is the “stick” and EHR payments and DSH payments (on the next slide) are the “carrot.”
  • When is an organization required to obtain audited financial statements?  There are various external reasons that an audit may be required. Many states have a revenue threshold that would trigger the audit requirement. For example, a New Jersey nonprofit organization that must file a Charitable Registration Form CRI-300R is required to attach a certified audit if its revenue exceeds $500,000 (increased from $250,000 in February 2011). An audit may also be required by an individual or government grantor, which should be addressed in the grant agreement. An organization that receives over $500,000 in federal grants is required to have an annual audit in accordance with OMB A-133. If an organization has bank or other financing arrangements, the lender may require that an annual audit be performed.
  • Presentation Explores Many Contexts of Community Benefit

    1. 1. Community Benefit: One Term, Many Contexts Presented by: David McMillan, CPA #AICPA_HEALTH 1
    2. 2. David W. McMillan, CPA PYA Principal David McMillan provides financial and strategic services to the Firm's healthcare clients. David's areas of concentration are: feasibility studies for various healthcare entities; mergers, acquisitions, and affiliations among providers; strategic planning and forecasting, clinical integration services; and valuations and operational analysis. American Institute of CPAs #AICPA_HEALTH 1
    3. 3. Overview In this session, we will examine the importance and meanings of community benefit. We will review the nuances within the Federal reporting requirements. We will also present best practices for developing a workplan to aid hospital staff, counsel, the CSuite, and the Board in preparing a uniform message. American Institute of CPAs #AICPA_HEALTH 1 2
    4. 4. Agenda Importance and Meaning of Community Benefit Federal Reporting Nuances for Community Benefit Economic Value of Community Benefit Community Benefit Uniform Message American Institute of CPAs #AICPA_HEALTH 1 3
    5. 5. Importance and Meaning of Community Benefit American Institute of CPAs #AICPA_HEALTH 1 4
    6. 6. Community Benefit Standard Adopted in 1969 by the IRS Basis for recognizing hospitals as income tax-exempt under Section 501(c)(3) of the Internal Revenue Code Most common test applied by IRS to determine if a hospital is operated to promote health in a manner that serves a charitable purpose and merits tax-exempt status American Institute of CPAs #AICPA_HEALTH 1 5
    7. 7. Public Perception Narrow interpretation = charity care Broad interpretation = virtually everything a non-profit hospital does Most common perception - mixture of the two interpretations American Institute of CPAs #AICPA_HEALTH 1 6
    8. 8. Demographics of Hospital Sector The American Hospital Association reports that there are more than 5,700 hospitals throughout the country. Of these, more than 2,900 are non-governmental notfor-profit hospitals. Around 1,025 are for-profit community hospitals. The remainder are state and local government hospitals. Per AHA Hospital Statistics, 2013 edition. Data from the 2011 annual survey. American Institute of CPAs #AICPA_HEALTH 1 7
    9. 9. Community Benefit Test – Federal Level Charities provide for a charitable class of people. (such as food, clothing, and shelter to the poor or distressed) A non-profit hospital, however, is required to show it benefits the community it serves through the promotion of health. • A non-profit hospital may provide services to persons outside of a charitable class. American Institute of CPAs #AICPA_HEALTH 1 8
    10. 10. Practice Perspective Catholic Health Association released a set of guidelines for hospitals to use in identifying community benefits: • To qualify as “community benefit,” the program must respond to an identified community need and meet at least one of the following criteria: Improve access to healthcare services within the community Improve health of the community Advance medical or health education within the community Relieve or reduce the burden of government or other community efforts American Institute of CPAs #AICPA_HEALTH 1 9
    11. 11. What is Community Benefit? American Institute of CPAs #AICPA_HEALTH 10 1
    12. 12. What does community benefit mean? The answer lies within the question, “How does one meaningfully differentiate a tax-paying, for-profit hospital from a non-profit hospital that enjoys exemption from federal and state tax, exemption from property tax, and eligibility for favorable bond financing?” American Institute of CPAs #AICPA_HEALTH 11 1
    13. 13. What is required for federal tax exemption? 1 Neither the Internal Revenue Code nor the underlying regulations explicitly provides for the exemption of non-profit hospitals from federal income taxation. 2 We have long recognized that hospitals may quality for exemption under section 501(c)(3). 3 Five Factors within the Community Benefit Standard American Institute of CPAs #AICPA_HEALTH 12 1
    14. 14. The Community Benefit Standard - 5 Factors 1 2 A community board An open medical staff 4 The admission of all types of patients including those able to pay for care either for themselves or through third-party payers American Institute of CPAs 3 A full-time emergency room open to all regardless of ability to pay 5 How excess funds are used, such as for expansion and replacement of existing facilities and equipment, medical training, education, and research #AICPA_HEALTH 13 1
    15. 15. Other Factors Facts and circumstances determination, with no one factor controlling Exemption also based on providing charity care American Institute of CPAs #AICPA_HEALTH 14 1
    16. 16. 501(c)(3) Considerations Community benefit standard is not the only requirement hospitals must satisfy Requirements for exemption under section 501(c)(3), including: • Prohibitions against inurement and the payment of excess compensation, and impermissible private benefit American Institute of CPAs #AICPA_HEALTH 15 1
    17. 17. Distinguishing Tax-Exempt from For-Profit An open medical staff, participation in Medicare and Medicaid, and treating all emergency patients without regard to ability to pay are characteristics now shared by tax-exempt and for-profit hospitals. Although they remain factors in assessing entitlement for tax exempt status, they no longer meaningfully distinguish one type of hospital from another. American Institute of CPAs #AICPA_HEALTH 16 1
    18. 18. State Tax Debate Provena case in Illinois proved that Federal tax exemption is no longer always dispositive of how a state or local government will regard a hospital. More than a dozen states have codified their hospital community benefit requirement in law or within regulations. Another nine have established community benefit requirements through broader hospital licensure laws, interpretive attorney general guidelines, and property tax exemption standards. American Institute of CPAs #AICPA_HEALTH 17 1
    19. 19. Legislative Intervention In July 2007, Finance Committee member Senator Grassley put forth a proposal to quantify the community benefit that tax-exempt hospitals ought to provide. • “No hospital can maintain section 501(c)(3) status without dedicating a minimum of 5% of its annual patient operating expenses or revenues to charity care, whichever is greater.” American Institute of CPAs #AICPA_HEALTH 18 1
    20. 20. IRS Form 990, Schedule H Intended to make “apples to apples” comparisons of hospitals Provides clearer standards on: • The types of activities reportable or not reportable as community benefit • The requirement that community benefit be reported at cost rather than charges, or otherwise • The requirement that community benefit be reported by employer identification number, rather than by hospital or by system American Institute of CPAs #AICPA_HEALTH 19 1
    21. 21. Federal Reporting Nuances for Community Benefit American Institute of CPAs #AICPA_HEALTH 20 1
    22. 22. Required Reporting IRS Form 990, Schedule H, Hospitals Medicare Cost Report – CMS Form 2552, Worksheet S-10 GAAP/Community Benefit Reporting American Institute of CPAs #AICPA_HEALTH 21 1
    23. 23. Definitions IRS Form 990, Schedule H CMS Form 2552, Worksheet S-10 Uncompensated Care Charity care and bad debt, which includes bad debt and Medicare bad debt. Uncompensated care does not include courtesy allowances or discounts. Charity Care • • • “…free or discounted health services provided to persons who meet the organization’s criteria for financial assistance and are thereby deemed unable to pay for all or a portion of the services” General Rule – if create a bill, no longer charity care, but might be bad debt if ultimately written off “Charity care” for Schedule H does NOT include: - Bad debt or uncollectible charges recoded but not paid - Medicare revenue shortfalls (exception – Subsidized Service Medicare Shortfalls are Community Benefit) - Contractual adjustments American Institute of CPAs Health services for which a hospital demonstrates that the patient is unable to pay. For Medicare purposes, charity care is not reimbursable and unpaid amounts associated with charity care are not considered as an allowable Medicare bad debt. #AICPA_HEALTH 22 1
    24. 24. Definitions IRS Form 990, Schedule H CMS Form 2552, Worksheet S-10 Bad Debt Health services for which a hospital determines the non-Medicare patient has the financial capacity to pay, but the non-Medicare patient is unwilling to settle the claim. Medicare Bad Debt Amount of allowable Medicare coinsurance and deductibles considered to be uncollectible but are not reimbursed by Medicare. Uninsured Patients Individuals with no source of third party healthcare coverage (insurance). Medically Indigent Patients Individuals who are unable to pay some or all of their medical bills because medical bills exceed a certain percentage of family income or assets. Usually defined by a hospital under its financial assistance policies. American Institute of CPAs Individuals who use or commit all available current and expected resources to pay for medical bills, and not limited to a defined percent of the Federal Poverty Guidelines, but follows specific hospital policy. #AICPA_HEALTH 23 1
    25. 25. Reporting Period Differences IRS Form 990, Schedule H Filed annually Based on FYE Electronic Filing Due Dates: up to 11 months after FYE American Institute of CPAs CMS Form 2552, Worksheet S-10 Filed annually Period can be shorter Electronic Filing Due dates: 5 months after FYE #AICPA_HEALTH 24 1
    26. 26. IRS Form 990, Schedule H Community Benefit - “The Chart” on Page 1 which we know is a focal point for various internal and external constituents – board, media, IRS, AG, etc. IRS tasked to conduct review and report on percentage of community benefit provided by hospital Lines 7a-7c focus on Charity Care, Medicaid, and other means tested programs American Institute of CPAs #AICPA_HEALTH 25 1
    27. 27. IRS Form 990, Schedule H Financial Assistance at Cost[1] Line 7a Schedule H Part I Line 7a-d Gross patient charges at the full established rates[4] Ratio of patient care cost to charges Estimated cost Medicaid provider taxes, fees, and assessments if payments received were intended primarily to offset the cost of the financial assistance Total community benefit expense Column C Net patient service revenue from Medicaid or other means-tested government programs Revenues received from a state organization to directly offset revenue for financial assistance Other direct offsetting revenue Total direct offsetting revenue Column D Medicaid[2] Other Meanstested Government Programs[3] T otal Line 7b Line 7c Line 7d X = + = + + = Net community benefit expense (community benefit expense – offsetting revenue) Column E Total expenses from the organization’s Form 990*5+ Percent of total expenses Column F ÷ = [1] Financial assistance is sometimes referred to as Charity Care. *2+ This includes Medicaid revenues and expenses from all states, not just the organization’s home state. *3+ “Other means-tested government programs” refers to government sponsored health programs (other than Medicare and Medicaid) with eligibility determined by the participants’ income or assets. *4+ Gross patient charges refer to only those written off under the organization’s FAP for Line 7a. For lines 7b and 7c, enter the gross patient charges for each applicable program. [5] Do not include bad debt expense in this total. American Institute of CPAs #AICPA_HEALTH 26 1
    28. 28. CMS Form 2552, Worksheet S-10 Required by all acute care hospitals, including Critical Access Hospitals CMS uses data from the worksheet to: Worksheet S-10 - Calculate the amount of a hospital’s EHR incentive payment - Determine the amount that a hospital will be paid from the Medicare uncompensated care pool DSH Change - Payments to a hospital cannot exceed the uncompensated costs of furnishing hospital services by the hospital to patients who are Medicaid-eligible or have no thirdparty coverage American Institute of CPAs #AICPA_HEALTH 27 1
    29. 29. CMS Form 2552, Worksheet S-10 EHR payments depend on the amount of charity care a hospital provides. • Inpatient Medicare Part A + Part C Days • Total charity care charges (Line 20 of S-10) American Institute of CPAs #AICPA_HEALTH 28 1
    30. 30. CMS Form 2552, Worksheet S-10 DSH payments reduced 75% beginning in 2014 • Portion of the reduction is returned as an additional payment for continued uncompensated care costs • Payment from the pool is determined by: Hospital’s percentage change in the % of uninsured from 2013 Hospital % of aggregate uncompensated care costs American Institute of CPAs #AICPA_HEALTH 29 1
    31. 31. CMS Form 2552, Worksheet S-10 Hospital Uncompensated and Indigent Care Data Uncompensated and indigent care cost computation Line Item Description 20 Partial payments by patients approved for charity care 23 Total Cost of initial obligation of patient approved for charity care (line 1 * line 20) 22 Insured Patients Total initial obligation of patients approved for charity care (at full charges excluding non-reimbursable cost centers) for the entire facility 21 Uninsured Patients Cost of charity care (line 21 minus line 22) • Uninsured Patients: list patients’ total charges • Insured Patients: patients covered by a public program or private insurer with which the provider has a contractual relationship American Institute of CPAs #AICPA_HEALTH 30 1
    32. 32. GAAP/Community Benefit Reporting GAAP  No revenue for charity care recognized on Financial Statements – only footnote disclosure  Charity care defined as “healthcare services that are provided but are never expected to result in cash flows”  Charity care is provided to a patient with demonstrated inability to pay  New amendment to ASC 954 requires cost be used as measurement  Includes both direct and indirect costs  Must disclose method used to determine cost American Institute of CPAs #AICPA_HEALTH 31 1
    33. 33. GAAP/Community Benefit Reporting GAAP  Medicaid and other means-tested programs shown as gross charges less contractual and other adjustments  Amounts reported on the accrual basis  Contractual and other adjustments can be based on estimates  Bad debts shown as a reduction in net patient revenue (for years ending after December 15, 2012) American Institute of CPAs #AICPA_HEALTH 32 1
    34. 34. GAAP/Community Benefit Reporting Community Benefit Reporting  No specific standards for reporting  Usually prepared by hospital marketing department  Many based on charges vs. cost  Not all hospitals issue report to community American Institute of CPAs #AICPA_HEALTH 33 1
    35. 35. Reporting Example Hospital Actual: Worksheet S-10 Uncompensated Care Actual: Form 990 Schedule H Charity Care Proposed Requirement: Charity Care Expense at 5% of Total Patient Revenue Hospital A $40,851,133 $18,343,174 $53,385,064 Hospital B $21,858,117 $12,959,865 $59,300,452 Hospital C $244,583,485 $137,924,438 $226,156,541 American Institute of CPAs #AICPA_HEALTH 34 1
    36. 36. Economic Value of Community Benefit American Institute of CPAs #AICPA_HEALTH 35 1
    37. 37. Community Benefit Valuation Qualitative Economic Value Quantitative American Institute of CPAs #AICPA_HEALTH 36 1
    38. 38. Qualitative Factors Proximity to Community Population • Can residents get to the facility with relative ease? Services Available to the Community • Can resident use the services provided? • Are there enough resources for residents? • Ability for organization to attract, retain, and grow talent. (No Docs, No Health Services) American Institute of CPAs #AICPA_HEALTH 37 1
    39. 39. Qualitative Factors Charity Care Capital Investment (e.g. Construction) Direct Employment Economic Impact American Institute of CPAs #AICPA_HEALTH 38 1
    40. 40. Value Determination Ultimate goal is to determine • Is the community better off because of the… Hospital? Affiliation? Merger? American Institute of CPAs #AICPA_HEALTH 39 1
    41. 41. Hospital Acquisition Laws Many states, such as Georgia and Louisiana, have hospital conversion laws whereby the Attorney General must review all transactions related to the acquisition or sale of assets of a non-profit hospital within the state to determine that sufficient community benefit will stem from the transaction. • In Georgia, the Attorney General must conduct a public hearing “to ensure that the public’s interest is protected when the assets of a nonprofit hospital are acquired by an acquiring entity by requiring full disclosure of the purpose and terms of the transaction and providing an opportunity for local public input.” • The statute continues the public interest emphasis by providing further that the “disposition of a nonprofit hospital to an acquiring entity shall not be in the public interest unless there has been adequate disclosure that appropriate steps have been taken to ensure that the transaction is authorized, to safeguard the value of charitable assets, and to ensure that any proceeds of the transaction are used for appropriate charitable healthcare purposes.” American Institute of CPAs #AICPA_HEALTH 40 1
    42. 42. Community Benefit Uniform Message American Institute of CPAs #AICPA_HEALTH 1
    43. 43. Develop a Workplan Identify Key Stakeholders Identify Reports • External Reports Develop a Reconciliation # • Internal Reports # American Institute of CPAs # # E.g., Decision Support, Finance, Marketing Identify Timeline • Audited Financial Statements #AICPA_HEALTH 41 1
    44. 44. Reconciliation Example Schedule S-10 Form 990 Sch H Difference Cost-to-Charge Ratio Total Expenses Less: Bad Debt Non-Allowable costs Non patient care activities Medicaid Provider Taxes Community benefit expenses Total Adjusted Cost Total Patient Charges Less: Non patient related charges Total Adjusted Charges CCR A B C E F G H J K L M = (H/L) 112,585,996 (19,247,068) (2,432,568) (849,936) (1,054,053) 112,339,761 (19,247,068) 89,002,371 387,479,075 (6,069,922) 381,409,153 0.233351 (2,001,826) (1,054,053) (119,456) 89,917,358 387,479,077 387,479,077 0.232057 N O M (M x N) 38,392,982 6,352,465 23.3351% 8,959,057 Q M R = (M x Q) 18,659,071 23.3351% 4,354,121 246,235 1 (914,987) (2) (6,069,924) 2 39,442,000 6,336,426 23.2057% 9,152,805 (1,049,018) 16,039 3 25,342,815 23.2057% 5,880,986 (6,683,744) Medicaid Gross Medicaid Revenue (Medicaid Charges) Net Medicaid Revenue Cost-to-Charge Ratio (CCR) Medicaid at Cost P= 4 (193,748) Charity Care Charity Care Charges Cost-to-Charge Ratio (CCR) Charity Care at Cost 1 2 5 (1,526,865) Expenses for Schedule H are from Audited Financial Statements Patient Charges for the Schedule H include gross inpatient and outpatient revenues. 3 External data (Summary Claims reports) is used to report Medicaid Revenue on S-10, whereas internal sources (financial statements) are used to report for on Schedule H. Differences relate to claims lag or payor classification. 4 The HS&R Report was used to report Net Medicaid Revenue for the S-10, whereas internal financial statements/general ledger reports were used for Schedule H. 5 Charity Care Charges per S-10 do not include amounts for indigent. American Institute of CPAs #AICPA_HEALTH 42 1
    45. 45. Educate the C-Suite and the Board Share listing of reports Share and discuss reconciliation American Institute of CPAs Share Timeline Prepare for answering questions from stakeholders, reporters, gov ernment officials, etc. #AICPA_HEALTH 43 1
    46. 46. Summary So what does the “community benefit” mean? We have to understand it in context. To value the economic benefit of community benefit, we have to include qualitative and quantitative factors. In reporting community benefit we have to be aware of the nuances between the various reporting mechanisms and reconcile those differences in a uniform message to the organization. American Institute of CPAs #AICPA_HEALTH 44 1
    47. 47. David McMillan, CPA Principal, Pershing Yoakley & Associates, P.C. (865) 673-0844 dmcmillan@pyapc.com #AICPA_HEALTH 45 1

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