2024 – CASE STUDY Major Medical Center For the Major Medical Center financial statements

CASE STUDY Major Medical Center For the Major Medical Center financial statements on the following pages, complete the following: a. Read the auditor’s opinion letter. Are any flags raised? b. Review the financial statements. Search for unusual items. W – 2024


Major Medical Center



For the Major Medical Center financial statements on the following pages, complete the following:

a.       Read the auditor’s opinion letter. Are any flags raised?

b.      Review the financial statements. Search for unusual items. What things catch your eye on the balance sheet, operating statement, and cash flow statement?

c.       Review the Notes. Do any of them raise cause for concern?

d.      Calculate the following ratios: common size, current, quick, days of cash on hand, receivables turnover, average collection period, fixed asset turnover, total asset turnover, debt, debt to equity, times-interest-earned, operating margin, total margin, Return on assets (ROA), and Return on net assets(RONA).

e.       What do you think of Major Medical Center’s financial status?




2650 East 38th Street

New York, New York 10089


Report of the Independent Auditors


Board of Trustees

Major Medical Center


We have audited the accompanying statements of financial position of Major Medical Center (the “Medical Center”) as of December 31, 2012 and 2011, and the related state of operation, changes in net assets, and cash flows for the years then ended. These financial statements are the responsibility of the Medical Centers management. Our responsibility is to express an opinion on these financial statements based on our audits.


            We conducted our audits in accordance with generally accepted auditing standards. Those standards require that we plan and perform the audit to obtain reasonable assurance about whether the financial statements are free of material misstatement. An audit includes examining, on a test basis, evidence supporting the amounts and disclosures in the financial statements. An audit also includes assessing the accounting principles used and significant estimates made by the management, as well as evaluating the overall financial statement presentation. We believe that our audits provide a reasonable basis for our opinion.


            In our opinion, the financial statements referred to above present fairly, in all material respects, the financial position of Major Medical Center at December 31, 2012 and 2011, and the results of its operations, changes in net assets, and cash flows for the years then ended, in conformity with generally accepted accounting principles.


April 30, 2013

                                                                                                                        I.N. SINGER AND OLD, CPAs


Major Medical Center

            Statements of Financial Position

                                                                                                                                    December 31


                                                                                                                                    2012                2011

                                                                                                                                    (In Thousands)                        ____________________________________________________________________________________


            Current Assets

                        Cash and cash equivalents                                                                   8,065               $9,065

                        Assets limited as to use -compensating balance

                           for letters of credit                                                                            1,000               ____

                        Short-term investments                                                                                    1,387                 1,283

                        Receivables for patient care, net of allowance for

                            doubtful accounts (2012-$27,232; 2011-$31,934)                         49,719             47,614

                        Pledges receivable                                                                               1,814               2,205

                        Inventories, at average cost                                                                  1,690               2,326

                        Due from third-party reimbursement programs                                                6,539               ____

                        Receivables for government grants                                                      ___                  467

                        Other                                                                                                   2,234                           3,415

                        Total Current Assets                                                                            72,448              66,315


Assets limited as to use:

                        Sinking fund                                                                                        14,487             13,410

                        Compensating balance for standby letters   of credit                                923               ____

                                                                                                                                    15,410             13,410

            Long-term investments                                                                                                  1,132                 618

            Due from affiliates, net                                                                                                 3,417               3,543

            Pledges receivable, net of allowance for uncollectible pledges           

                        (2012 – $2,218; 2011 – $4,453)                                                                         1,889               1,468

            Property, plant, and equipment net                                                                  98,555             89,777

            Deferred financing costs                                                                                    1,323               ____

            Other                                                                                                                 2,065               1,043

                                                                                                                                                $196,239       $176,174                                       

            Liabilities and Net Assets

            Current Liabilities

                        Current portion of long-term debt                                                       $11,608                  $11,488

                        Accounts payable and accrued expenses                                                         29,489         25,311                 Accrued salaries and related liabilities                                                             25,572        20,096

                        Due to third-party reimbursement programs, net                                                ____           1,874

                        Advances on government grants                                                             1,587           ___

                        Total Current liabilities                                                                                    68,256        58,769


            Long term debt, less current portion                                                                55,539                        47,709

            Accrued post-retirement benefits                                                                        6,023                          6,017

            Other noncurrent liabilities                                                                               16,445                        17,014

            Total Liabilities                                                                                                            146,263           129,509

            Commitments and contingencies


            Net Assets

                        Unrestricted                                                                                         40,582             38,014            Temporarily restricted                                                                             8,262                          7,519            Permanently restricted                                                                            1,132                          1,132                         Total Net Assets                                                                          49,976              46,665

                                                                                                                                  $196,239          $176,174                  __________________________________________________________________________________

See accompanying notes.



Major Medical Center

   Statements of Operations   



                                                                                                            Year ended December 31                                                                                                                   _______________________

                                                                                                                        2012                2011


                                                                                                                        (In Thousands)


            Operating Revenue                 

            Net patient service revenue                                                                  $402,921         369,512

            Other revenue                                                                                          13,356           13,850

            Net assets released from restrictions                                                    __ 4,708                2,863

                        Total Operating Revenue                                                            420,985           386,225                                                                               

            Operating Expenses                                                                            

            Salaries and wages                                                                               207,141           196,453

            Employee benefits                                                                                 44,456                        44,860

            Supplies and expenses                                                                         137,505                         117,838            Depreciation and amortization                                                               22,541                         18,856            Research                                                                                                  2,457                            2,214

            Interest                                                                                                    4,456                            5,253

                        Total Operating Expenses                                                        418,556                          385,474                   

Operating Income                                                                                    2,429                                 751

Net assets released from restrictions used for capital acquisitions                         139                        146

            Increases in unrestricted net assets                                                       $2,568                                $897


            See accompanying notes.


















Major Medical Center

Statements of Changes in Net Assets


                                                                                                            Net Assets


                                                                                                                        Temporarily   Permanently                                                                                       Unrestricted      Restricted        Restricted


                                                                                                                        (In Thousands)


            Net Assets as December 31, 2010                                $37,117            $3,023                                $1,132

            Increase in unrestricted net assets                                       897                   ___                                  ___        

            Restricted contributions, grants, another receipts                             ___             7,253                                    ___

            Investment income restricted for specific purposes                       ___                    252                      ___

            Net assets released from restrictions for:                 

                        Operating expenses                                                            ___                (2,863)                      ___        

                        Capital asset acquisitions                                       ___                  (146)                        ___

            Change in net assets                                                           897                             4,496                                   ___

            Net Assets at December 31, 2011                                38,014                             7,519                                   1,132

            Increase in unrestricted net assets                                2,568                    ___                                    ___   

            Restricted contributions, grants, and other receipts         ___                  5,421                                      ___

            Investment income restricted for specific purposes        ___                     169                                      ___

            Net assets released from restrictions for:

                        Operating expenses                                             ___                  (4,708)                      ___

                        Capital asset acquisitions                                 ______                              (139)                      ___

            Change in net assets                                                     2,568_                            __743_                    ___

            Net Assets on December 21, 2012                               $40,582                           $8,262                  $1,132


See accompanying notes.


















Major Medical Center

Statements of Cash Flows


                                                                                                                        Year Ended December 31


                                                                                                                                    2012                2011


                                                                                                                                    (In thousands)


        Operating Activities                                                                                        

        Operating income                                                                                            $2,429                          $751

        Change in temporarily restricted net assets                                                            743             4,496

                                                                                                                                   3,172               5,247

        Adjustments to reconcile change in net assets to cash provided by operations:

                    Depreciation and amortization                                                                  22,541       18,856

                    Investment income earned on assets limited as to use                                        (774)               (698)

                    Changes in operating assets and liabilities:

                      (Increase) decrease in receivables for patient care                                         (2,105)              7,589

                      (Increase) decrease in due from third-party reimbursement programs               (8,413)           4,500

                      Increase in accounts payable and accrued expenses

                      and accrued salaries and related liabilities                                                9,654          1,412

                    Net effect of increases and decreases in other assets and liabilities           2,286          (8,707)

        Cash provided by operations                                                                               26,361           28,199


Investing Activities     

        Acquisitions of property, plant, and equipment, net                                             (10,043)       (12,998)

           Less amounts provided by restricted funds                                                                      139               146

        Increase in investments                                                                                                        (618)             (70)

        Cash used in investing activities                                                                                      (10,552)     (12,922)


        Financing Activities    

        Net payment from (to) affiliates                                                                                            126         (1,773)               Increase in deferred financing costs                                                                      (1,323)      

        Repayments of long-term debt                                                                              (13,326)        (9,510)

        Deposits into sinking fund, as required by mortgage loan agreement                         (303)     

        Increase in compensating balances for standby letters of credit                                          (1,923)

        (Increase) decrease in pledges receivable                                                                  (30)        (3,190)

        Cash used in financing activities                                                                                       (16,779)      (14,473)

        Net (decrease) increase in cash and cash equivalents                                                (940)          804

        Cash and cash equivalents at beginning of year                                                                    9,005        8,201

        Cash and cash equivalents at end of year                                                                          $8,065       $9,005


       See accompanying notes.
Accompanying Notes to Financial Statements

1.      Organization and Summary of Significant Accounting Policies



Major Medical Center (the “Medical Center”) is a not-for-profit corporation. The Medical Center      provides health care and related services. The accompanying financial statements do not include the accounts of the Research Foundation, a not-for-profit corporation that solicits funds and awards grants to the Medical Center for research purposes, nor for Hospital Support, Inc., which provides certain support services.


Temporarily and Permanently Restricted Net Assets

Temporarily restricted net assets are those whose use by the Medical Center has been limited by donors to a specific time period or purpose. Permanently restricted net assets have been restricted by donors to be maintained by the Medical Center in perpetuity. When a donor restriction expires (i.e., when a stipulated time restriction ends or purpose restriction is accomplished), temporarily restricted net assets are reclassified as unrestricted net assets and reported in the statements of operations as net assets released from restrictions. Donor restricted contributions whose restrictions are met within the same year as received are reflected as temporarily restricted contributions and net assets released from restrictions in the accompanying financial statements.


Receivables for Patient Care

Patient accounts receivable from third-party programs for which the Medical Center receives payment under reimbursement formulas or negotiated rates are stated at the estimated net amounts receivable from such payors, which are generally less than the established charges of the Medical Center.



Investments consist of U.S. Treasury bonds and notes, certificates of deposit, and money market funds. Investments are carried at fair value. Amounts classified as long-term investments, consisting primarily of money market funds, represent permanently restricted net assets.


Investment Gains, Losses, and Income

Investment income, which includes real gains and losses, earned on permanently restricted and temporarily restricted funds upon which restrictions have been placed by donors, is added to temporarily restricted funds. All other investment income is reflected in the accompanying statements of operations.


Property, Plant, and Equipment

Property, plant, and equipment purchased are carried at cost, and those acquired by gifts and bequests are carried at appraised or fair market value established at the date of acquisition. Capitalized leases are recorded at the fair market value at the inception of the leases. The carrying amounts of assets and the related accumulated depreciation are removed from the accounts when such assets are disposed of, and any resulting gain or loss is included in operations. Depreciation of assets used in operations is recorded on the straight-line method over the estimated useful lives of the assets. Capitalized leases are amortized over the lease term.



Unconditional promises to give cash and other assets are reported at their net present value at the date the promise is received. The gifts are reported as either temporarily or permanently restricted support if they are received with donor stipulations that limit the use of the donated assets. Pledges receivables, discounted at 10 percent, are expected to be paid as follows (in thousands):

                        Less than one year                                           $ 1,814

                        One year to five years                                                    3,145

                        In excess of five years                                     ___962___


                        Less allowance for

                           uncollectible pledges receivable                    (2,218)

                                                                                                  $ 3,703         



Assets Limited as to Use

Assets classified as limited as to use represent assets whose use is restricted for specific purposes under terms of agreements.


Accrued Post-Retirement Benefits

The Medical Center accounts for post-retirement health care and life insurance benefits on the accrual basis of accounting.


Uncompensated Care

As a matter of policy, the Medical Center provides significant amounts of partially or totally uncompensated patient care. For accounting purposes, such uncompensated care is treated either as charity care or bad debt expense. The Medical Center has defined charity care for accounting and disclosure purposes as the difference between its customary charges and the sliding scale rates given to patients in need of financial assistance. Since payment of this difference is not sought, charity care allowances are not reported as revenue. Patients who do not qualify for sliding scale fees and all uninsured inpatients who do not qualify for Medicaid assistance are billed at the Medical Center’s full rates. Uncollected balances for these patients are categorized as bad debts. Total uncompensated care for all patient services approximated $22 million and $20 million in 2012 and 2011, respectively.


Use of Estimates

The preparation of financial statements in conformity with generally accepted accounting principles requires management to make estimates and assumptions that affect the reported amount of assets and liabilities and the disclosure of contingent assets and liabilities at the date of the financial statements. Estimates also affect the reported amounts of revenue and expenses during the reporting period. Actual results could differ from these estimates. Management believes that the amounts recorded based on estimates and assumptions are reasonable, and any differences between estimates and actual should not have a material impact on the Medical Center’s financial position.


Operating Income

Transactions deemed by management to be ongoing, major, or central to the provision of health care services are reported as operating revenue and expenses, and are included in operating income. Operating income also includes investment income and realized gains and losses from the sale of investments.


Tax Status

The Medical Center is exempt from federal income taxes under Section 501(c)(3) of the Internal Revenue Code. The Medical Center has been classified as an organization that is not a private foundation under Section 509(a)(1). Contributions received by the Medical Center qualify as tax-deductible charitable contributions.


2. Third-Party Reimbursement Programs


The Medical Center has agreements with third-party payers that provide for payments to the Medical Center at amounts different from its established charges. Payment arrangements include prospectively determined rates per discharge, reimbursement of costs, discounted charges, and per diem payments. Patient service revenue is recorded at the Medical Center’s established charges when patient services are performed. Adjustments for differences between established charges and payment amounts are deducted directly from receivables for patient care and patient service revenue in the year incurred.

            Federal and state regulations provide for certain retrospective adjustments to current and prior years’ payment rates based on industry wide and hospital-specific data. The Medical Center has estimated the potential impact of such retrospective adjustments based on information presently available, and adjustments are accrued on an estimated basis in the period the services are rendered and are adjusted in future periods as final settlements are determined. Management believes that amounts recorded in the accompanying financial statements will not be materially affected upon the final settlement of such retrospective adjustments.


Hospitals are reimbursed for Medicare inpatient services under the national prospective payment system (“PPS”) and other methodologies of the Medicare program for patient services. Such Medicare payments are based on a blend of national industry and hospital specific data. The Medicaid program pays rates determined by the state, primarily on a basis of prospectively determined rates per discharge. The Medical Center is paid by non-Medicare/Medicaid payers based on negotiated contract amounts or, if such contracts do not exist, at the Medical Center’s established charges. In addition, the state has requested a waiver from the federal government that will allow it to enroll substantially all of its Medicaid participants into Medicaid managed care programs. The ultimate outcome and effect of these changes and proposals on the Medical Center’s future operations cannot presently be determined. In 2012, net revenue from the Medicare and Medicaid programs accounted for 44 percent and 23 percent, respectively, of total net patient service revenue.


3. Assets Limited as to Use


A summary of assets limited as to use is as follows at December 31:


                                                                                                            2012                            2011


                                                                                                                       (In Thousands)


                                       Sinking Funds:                       

                                                Cash and cash equivalents                   $276                            $249

                                                U.S. government and

                                             agency obligations                            14,211                         13,161

                              Total Sinking Funds                                         14,487                         13,410


Collateral for Standby Letters of Credit:

                                                Cash and cash equivalents                      582                           _____

                                                Corporate bonds                                  1,341                          _____

                                    Total Collateral for Standby

                                                Letters of Credit                                     1,923                         _____

                                    Total Assets Limited as to Use                           $16,410                                 $13,410



4. Property, Plant, and Equipment


A summary of property, plant, and equipment is as follows at December 31:


                                                                                                            2012                            2011


                                                                                                                        (In Thousands)


                                    Land                                                                $ 4,980                                      $ 4,980

                                    Buildings                                                          58,827                                      58,827

                                    Equipment                                                       164,592                       140,707

                                                                                                            228,399                                    204,514

                                    Less accumulated depreciation                                     141,502                      125,148                                                                                                                         86,897                                   79,366

                                    Projects in progress                                            11,658                                      10,411

                                                                                                           $98,555                        $89,777



            Approximately $45,673,000 and $45,706,000 of fully depreciated assets are included in buildings and equipment at December 31, 2012 and 2011, respectively. Substantially all property, plant, and equipment is pledged as collateral under various loan agreements.


Capitalized equipment leases, included in property, plant, and equipment, areas follows at December 31:


                                                                                                            2012                            2011


                                                                                                                       (In Thousands)


                                    Assets recorded under capital leases                $67,434                                   $51,695

                                    Less accumulated amortization                                       35,911                                  27,108

                                                                                                            $31,523                                   $24,587




5. Long-Term Debt

A summary of long-term debt is as follows at December 31:


                                                                                                2012                            2011


                                                                                                           (In Thousands)


                                    FHA Section 242 insured                    

                                                mortgage loan (a)                     $20,865                       $ __

                                    FHA Section 241

                                             mortgage loan (a)                       10,941                       12,125

                                    2005 mortgage loan (b)                                         2,216                                 2,758

                                    1998 insured mortgage loan (a)                             __                          15,492

                                    Various mortgages, having

                                        interest rates ranging from 3.5%

                                         to 10.0%, maturing at various

                                        dates  through 2008                                        2,020                                    2,892

                                    Capitalized leases (c)                           31,105                                     25,930

                                                                                                67,147                         59,197

                                    Less current portion                             11,608                                      11,488

                                                                                                $55,539                       $47,709



a)      As a condition of these borrowings, the Medical Center is required to establish and maintain a sinking fund. Amounts deposited into the sinking fund, together with investment earnings therein, are available for principal payments and purchases of specified levels of capital assets. Assets on deposit in the sinking fund at December 31, 2012 and 2011, are in compliance with the required amounts.


b)      Annual principal payments for all long-term debt, excluding capital leases and required sinking fund balances for the next five years, are as follows:









                                                                                    Principal                     Sinking Fund

                                                                                    Payments                        Balance


                                                                                                       (In Thousands)



                                                2013                            $2,789                         $15,461

                                                2014                              4,688                          14,937

                                                2015                              4,157                           14,162

                                                2016                              4,089                           13,129

                                                2017                             3,746                           11,831





c). Future minimum payments, by year and in the aggregate, under capitalized leases consisted of the following at December 31, 2012 (in thousands):


                                                2013                                                                $11,102

                                                2014                                                                    9,852

                                                2015                                                                    8,204

                                                2016                                                                    4,744

                                                2017                                                                    1,518

                                                Thereafter                                                               850

                                                Total minimum lease payments                                      36,270

                                                Less amounts representing interest                      (5,165)

                                                Present value of lease payments                                  $31,105



6. Retirement and Similar Benefits


The Medical Center provides retirement and similar benefits to its union employees through several defined benefit multi-employer pension plans and to its nonunion employees through a noncontributory defined benefit pension plan and tax-deferred annuity plans. Payments to the defined benefit multi-employer union plans are made in accordance with contractual arrangements under which contributions are generally based on gross salaries and are funded on a current basis. The Medical Center contributes amounts to the nonunion plan sufficient to meet the minimum funding requirements set forth in the Employee Retirement Income Security Act of 1974. The Medical Center’s pension expense under all existing plans aggregated approximately $10,202,000 and $10,683,000 for the years ended December 31, 2012 and 2011, respectively.


7. Other Post-Retirement Benefits


In addition to the pension plans and the tax-sheltered annuity plans described in Note 6, the Medical Center sponsors a defined benefit health care plan that provides post-retirement medical, dental, and life insurance benefits to certain full-time employees hired prior to July 1,2004, and who have worked 10 years and attained age 65 while in service with the Medical Center. The plan contains cost-sharing features such as deductibles and coinsurance.

Effective in May 2012, the Medical Center changed the type of the plan from basic hospi­tal plus major medical to a point-of-service plan for nonunion employees. The effects of this change have been reflected in the actuary’s calculation for the plan year ended December 31, 2012. At the end of 2012 and 2011, the accrued post-retirement benefit cost was $6,023,000 and $6,017,000, respectively. As of December 31, 2012 and 2011, the plan was unfunded.


8. Government Grants


The Medical Center receives grants from various government agencies. For the contract years ending June 30, 2013, 2014, and 2015, these grant awards are as follows:


                                                Contract Year                                                  Amount

                                                Ending June 30:                                  (In Thousands)                                                                        _____________________________________________________ 

                                                2013                                                    $3,791

                                                2014                                                      3,513

                                                2015                                                      3,765



            Advances on government grants of $1,587,000 at December 31, 2012, as reflected in the accompanying statement of financial position, represent amounts received from the granting agencies in excess of claims made at that date. The receivable amount of $467,000 at December 31, 2011, represents claims made in excess of advances received from the granting agencies at that date.


9. Professional Liability Insurance


The Medical Center participates in a pooled program with certain other health care facilities (principally medical centers) for professional liability insurance. This participation is with captive insurance companies and, with the other health care facilities, in a pooled layer for additional insurance with commercial insurance companies.


During 2011, the Medical Center had an aggregate deposit of $2,000,000 with two of the captive insurance companies. During 2012, these deposits were replaced with two letters of credit of $1,000,000 each. The deposits were included in other current assets in the accompanying 2011 statement of financial position.


Malpractice claims in excess of insurance coverage have been asserted against the Medical Center by various claimants. The claims are in various stages of processing, and some may ultimately be brought to trial. Medical Center management and counsel are unable to conclude about the ultimate outcome of the actions. There are known incidents occurring through December 31, 2012, that may result in the assertion of additional claims, and other claims may be asserted arising from services provided to patients in the past. It is the opinion of Medical Center management, based on prior experience, that adequate insurance is maintained to cover all significant professional liability losses.


10. Transactions with Affiliates


The amounts due from affiliates in the accompanying statements of financial position at December 31, 2012 and 2011, include a $1,900,000 loan receivable and accrued interest thereon from Hospital Support, Inc. The loan, which does not have specified repayment terms, bears interest at the prime rate, which approximated 7.75 percent at December 31, 2012 and 2011.


11. Temporarily and Permanently Restricted Net Assets

Temporarily restricted net assets are available for the following purposes at December 31:





                                                                                                2012                            2011


                                                                                                           (In Thousands)


                                    Research and education                                   $ 817                           $2,502            

                                    Plant replacement and expansion         7,445                            5,017

                                                                                                $8,262_                                   $7,519



            Permanently restricted net assets at both December 31, 2012 and 2011 consist of investments to be held in perpetuity and whose income is restricted as to use.


12. Other Operating Revenue


Other operating revenue consisted of the following for the year ended December 31:



                                                                                                2012                            2011


                                                                                                          (In Thousands)


                                    Government grant income                 $ 1,668                          $ 5,053

                                    Real estate rentals                                2,838                              2,651

                                    Investment income and gains  

                                                on sale of investments             1,077                              1,044

                                    Faculty practice and research

                                                overhead                                  5,703                              2,079

                                    Dining room and parking

                                                lot income                                   996                                 958

                                    Grants and contributions                         343                                 499

                                    Other                                                        731                           1,566

                                                                                                $13,356                                    $13,850

13. Concentration of Credit Risk


Significant concentrations of patients accounts receivable include 30 percent and 37 percent from government-related programs, 6 percent and 8 percent from Empire Blue Cross and Blue Shield, and 27 percent and 23 percent from Cambridge Health Plans at December 31, 2012 and 2011, respectively.

At December 31, 2012, 95 percent of the Medical Center’s cash and cash equivalents balance was held at one financial institution.


14. Fair Value of Financial Instruments


The following methods and assumptions were used by the Medical Center in estimating its fair value disclosures for financial instruments: The carrying amount reported in the statements of financial position for cash and cash equivalents approximates its fair value. Short-term investments consist primarily of government and other debt securities. Fair values are based on quoted market prices. Long-term investments consist primarily of money market funds. Fair values are based on quoted market prices. Assets limited as to use consist primarily of government securities. Fair values are based on quoted market prices. Most of the long-term debt of the Medical Center was refinanced during 2006. The carrying value of the Medical Center’s long-term debt at December 31, 2012, approximates its fair value.


15. Contingencies


The Medical Center is a defendant in various legal actions arising out of the normal course of its operations, the final outcome of which cannot presently be determined. The amounts claimed would be material to the financial position of the Medical Center. Medical Center management is of the opinion that ultimate liability, if any, with respect to all of these matters will not have a material adverse effect on the Medical Center’s financial position.

Approximately 67 percent of the Medical Center’s employees are members of various unions. Of these employees, approximately 70 percent are covered by contracts expiring during 2013.

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