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ObjectId: 202331359349320563 - Submission: 2023-05-15
TIN: 73-1034824
Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
Attach to Form 990.
Go to
www.irs.gov/Form990
for instructions and the latest information.
OMB No. 1545-0047
20
21
Open to Public Inspection
Name of the organization
INTEGRIS BAPTIST MEDICAL CENTER INC
Employer identification number
73-1034824
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed on Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
First-class or charter travel
Housing allowance or residence for personal use
Travel for companions
Payments for business use of personal residence
Tax idemnification and gross-up payments
Health or social club dues or initiation fees
Discretionary spending account
Personal services (e.g., maid, chauffeur, chef)
b
If any of the boxes on Line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain
.....
1b
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked on Line 1a?
....
2
3
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
Compensation committee
Written employment contract
Independent compensation consultant
Compensation survey or study
Form 990 of other organizations
Approval by the board or compensation committee
4
During the year, did any person listed on Form 990, Part VII, Section A, line 1a, with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment?
.............
4a
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan?
.........
4b
Yes
c
Participate in, or receive payment from, an equity-based compensation arrangement?
.........
4c
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.
5
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization?
....................
5a
No
b
Any related organization?
.......................
5b
No
If "Yes," on line 5a or 5b, describe in Part III.
6
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization?
..................
6a
No
b
Any related organization?
......................
6b
No
If "Yes," on line 6a or 6b, describe in Part III.
7
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization provide any nonfixed
payments not described in lines 5 and 6? If "Yes," describe in Part III
............
7
Yes
8
Were any amounts reported on Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III
..........................
8
No
9
If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)?
.........................
9
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2021
Page 2
Schedule J (Form 990) 2021
Page
2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees.
Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported on Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note.
The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(A)
Name and Title
(B)
Breakdown of W-2, 1099-MISC compensation, and/or 1099-NEC
(C)
Retirement and other deferred compensation
(D)
Nontaxable
benefits
(E)
Total of columns
(B)(i)-(D)
(F)
Compensation in column (B) reported as deferred on prior Form 990
(i)
Base
compensation
(ii)
Bonus & incentive
compensation
(iii)
Other
reportable compensation
1
TIMOTHY PEHRSON
DIRECTOR & PRESIDENT/CEO
(i)
(ii)
0
-------------
1,150,996
0
-------------
659,360
0
-------------
131,860
0
-------------
280,336
0
-------------
17,939
0
-------------
2,240,491
0
-------------
114,191
2
JAMES LONG
PHYSICIAN
(i)
(ii)
1,243,405
-------------
0
0
-------------
0
29,864
-------------
0
11,600
-------------
0
0
-------------
0
1,284,869
-------------
0
0
-------------
0
3
ALY EL BANAYOSY
PHYSICIAN/MEDICAL DIRECTOR
(i)
(ii)
928,248
-------------
0
59,445
-------------
0
16,073
-------------
0
19,225
-------------
0
0
-------------
0
1,022,991
-------------
0
0
-------------
0
4
DOUGLAS M SMITH
TREASURER & CFO
(i)
(ii)
0
-------------
553,425
0
-------------
230,406
0
-------------
13,051
0
-------------
123,939
0
-------------
17,340
0
-------------
938,161
0
-------------
0
5
JULIE WATSON
FORMER DIRECTOR
(i)
(ii)
0
-------------
611,261
0
-------------
102,346
0
-------------
11,035
0
-------------
109,168
0
-------------
1,252
0
-------------
835,062
0
-------------
0
6
VIVEK KOHLI
PHYSICIAN
(i)
(ii)
722,389
-------------
0
24,446
-------------
0
27,027
-------------
0
21,059
-------------
0
0
-------------
0
794,921
-------------
0
0
-------------
0
7
ABBASS RAZA
PHYSICIAN/MEDICAL DIRECTOR
(i)
(ii)
713,850
-------------
0
15,503
-------------
0
23,364
-------------
0
17,714
-------------
0
0
-------------
0
770,431
-------------
0
0
-------------
0
8
DOUGLAS A HORSTMANSHOF
PHYSICIAN/MEDICAL DIRECTOR
(i)
(ii)
744,604
-------------
0
0
-------------
0
1,884
-------------
0
22,125
-------------
0
0
-------------
0
768,613
-------------
0
0
-------------
0
9
ALLISON PETERSEN
DIRECTOR
(i)
(ii)
0
-------------
401,580
0
-------------
148,801
0
-------------
11,790
0
-------------
100,418
0
-------------
17,173
0
-------------
679,762
0
-------------
0
10
KERRI BAYER
CHIEF NURSING OFFICER
(i)
(ii)
336,903
-------------
0
124,724
-------------
0
13,209
-------------
0
87,171
-------------
0
17,286
-------------
0
579,293
-------------
0
0
-------------
0
11
JORDAN CASH
CHIEF HOSPITAL EXECUTIVE
(i)
(ii)
0
-------------
277,972
0
-------------
75,238
0
-------------
69,832
0
-------------
36,437
0
-------------
8,255
0
-------------
467,734
0
-------------
62,224
12
LEWIS L PERKINS
CHIEF NURSING OFFICER
(i)
(ii)
192,532
-------------
0
132,072
-------------
0
7,359
-------------
0
0
-------------
0
0
-------------
0
331,963
-------------
0
0
-------------
0
Schedule J (Form 990) 2021
Page 3
Schedule J (Form 990) 2021
Page
3
Part III
Supplemental Information
Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II. Also complete this part for any additional information.
Return Reference
Explanation
PART I, LINE 3
INTEGRIS BAPTIST MEDICAL CENTER, INC. (IBMC) IS A MEMBER OF AN INTEGRATED HEALTHCARE SYSTEM CONTROLLED BY INTEGRIS HEALTH, INC. (INTEGRIS). AS PART OF THIS SYSTEM, IBMC RELIES UPON INTEGRIS TO ESTABLISH THE COMPENSATION FOR ITS TOP MANAGEMENT OFFICIALS. INTEGRIS UTILIZES A COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE TO ESTABLISH THIS COMPENSATION.
PART I, LINE 4B
THE FILING ORGANIZATION IS A MEMBER OF AN INTEGRATED HEALTHCARE SYSTEM CONTROLLED BY INTEGRIS HEALTH, INC. (INTEGRIS). INTEGRIS PROVIDES TO CERTAIN EXECUTIVES A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN. THE PURPOSE OF THE PLAN IS TO SUPPLEMENT THE SPONSOR-PROVIDED RETIREMENT BENEFITS TO BE PAID TO SENIOR EXECUTIVES PURSUANT TO THE DEFINED BENEFIT PENSION PLAN, THE TAX DEFERRED ANNUITY PLAN AND OTHER QUALIFIED OR NON QUALIFIED RETIREMENT PLANS WHICH ARE MAINTAINED BY THE SPONSOR. THE PLAN PROVIDES AN OPPORTUNITY TO EARN SUPPLEMENTAL INCENTIVE INCOME BY PROVIDING ANNUAL CONTRIBUTIONS TO THE ACCOUNT SO LONG AS THE EXECUTIVE REMAINS EMPLOYED BY THE SPONSOR TO RETIREMENT AGE OF 65. THE FOLLOWING INDIVIDUAL LISTED IN PART VII OF FORM 990 PARTICIPATED IN THIS PLAN BUT DID NOT RECEIVE A PAYMENT IN THE CURRENT REPORTING YEAR: DOUGLAS M. SMITH THE FOLLOWING INDIVIDUALS LISTED IN PART VII OF FORM 990 PARTICIPATED IN THIS PLAN AND RECEIVED PAYMENTS IN THE CURRENT REPORTING YEAR: JORDAN D. CASH - $ 62,224 TIMOTHY PEHRSON - $114,191
PART I, LINE 7
THE FILING ORGANIZATION IS A MEMBER OF AN INTEGRATED HEALTHCARE SYSTEM CONTROLLED BY INTEGRIS HEALTH, INC. (INTEGRIS). INTEGRIS HEALTH HAS ESTABLISHED A FINANCIAL INCENTIVE PLAN THAT ENCOURAGES THE EXECUTIVE OFFICER'S PARTICIPATION IN THE SIGNIFICANT IMPROVEMENTS OF THE QUALITY AND FINANCIAL OPERATIONS OF THE ORGANIZATION. THE QUALITY COMPONENT IS DEFINED AS IMPROVEMENT IN PATIENT SAFETY, PATIENT SATISFACTION AND REDUCTION OF EMPLOYEE TURNOVER. THE FINANCIAL COMPONENT CONSISTS OF ACHIEVEMENT IN NET OPERATING INCOME THRESHOLD TO BE ACHIEVED TO ACTIVATE THE PLAN. A PREDETERMINED THRESHOLD IS CREATED WITHIN ALL ASPECTS OF THE PLAN BEFORE FINANCIAL ACHIEVEMENT IS PAYABLE. ALL PLANS ARE WRITTEN ACCORDING TO EXECUTIVE LEVEL AND ADOPTED BY INTEGRIS HEALTH BOARD RESOLUTION EACH PLAN YEAR AND PAYABLE AFTER INDEPENDENT AUDIT RESULTS ARE DETERMINED. IN THE SECOND PLAN, CERTAIN EMPLOYED PHYSICIANS ARE ELIGIBLE TO RECEIVE INCENTIVE COMPENSATION PURSUANT TO THEIR WRITTEN EMPLOYMENT AGREEMENTS. ALL INCENTIVE COMPENSATION IS SUBJECT TO A CAP AND DOES NOT EXCEED 50% OF THE PHYSICIAN'S TOTAL COMPENSATION. THERE ARE A VARIETY OF METHODS USED TO CALCULATE INCENTIVE COMPENSATION BASED ON THE PHYSICIAN'S PERSONAL PRODUCTION, RANGING FROM (I) A SPECIFIED PERCENTAGE OF NET INCOME LESS EXPENSES; (II) A SPECIFIED PERCENTAGE OF TOTAL COLLECTIONS LESS EXPENSES; (III) A SPECIFIED PERCENTAGE OF BASE SALARY BASED COMPLIANCE WITH CERTAIN QUALITY, PATIENT SATISFACTION, PRODUCTION AND FINANCIAL INDICATORS; (IV) A SPECIFIED PERCENTAGE OF BASE SALARY BASED ON COMPLIANCE WITH QUALITY, GUIDING VALUES, PATIENT SATISFACTION AND PRODUCTRION CRITERIA; (V) A SPECIFIED PERCENTAGE OF FEE-BASED COLLECTIONS AND CAPITATION COLLECTIONS, IF APPLICABLE, IN EXCESS OF QUARTERLY SALARY; (VI) QUARTERLY BONUSES MEASURED BY RVUS THAT EXCEED A SPECIFIED TARGET PER QUARTER; AND (VII) PRO RATA SHARE OF ANNUAL INCENTIVE POOLS BASED UPON PRODUCTION, COMPLIANCE WITH CLINICAL GUIDELINES, QUALITY AND PATIENT SATISFACTION CRITERIA.
Schedule J (Form 990) 2021
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