Mount Sinai Medical Center of Florida, Inc. and Subsidiaries

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1 Mount Sinai Medical Center of Florida, Inc. and Subsidiaries Consolidated Financial Statements as of and for the Years Ended December 31, 2011 and 2010, Supplemental Information for the Year Ended December 31, 2011, and Independent Auditors Reports in Accordance with Government Auditing Standards, OMB Circular A-133, and State of Florida Rules of the Auditor General, Chapter

2 MOUNT SINAI MEDICAL CENTER OF FLORIDA, INC. AND SUBSIDIARIES TABLE OF CONTENTS INDEPENDENT AUDITORS REPORT 1 2 CONSOLIDATED FINANCIAL STATEMENTS AS OF AND FOR THE YEARS ENDED DECEMBER 31, 2011 AND 2010: Balance Sheets 3 Statements of Operations and Changes in Net Assets 4 5 Statements of Cash Flows 6 7 Notes to Consolidated Financial Statements 8 29 SUPPLEMENTAL INFORMATION AS OF AND FOR THE YEAR ENDED DECEMBER 31, 2011: 30 Page Supplemental Consolidating Balance Sheet Information Supplemental Consolidating Statement of Operations Information 33 Supplemental Schedule of Expenditures of Federal Awards and State Financial Assistance Notes to Supplemental Schedule of Expenditures of Federal Awards and State Financial Assistance 36 INDEPENDENT AUDITORS REPORT ON INTERNAL CONTROL OVER FINANCIAL REPORTING AND ON COMPLIANCE AND OTHER MATTERS BASED ON AN AUDIT OF FINANCIAL STATEMENTS PERFORMED IN ACCORDANCE WITH GOVERNMENT AUDITING STANDARDS INDEPENDENT AUDITORS REPORT ON COMPLIANCE WITH REQUIREMENTS THAT COULD HAVE A DIRECT AND MATERIAL EFFECT ON EACH MAJOR FEDERAL PROGRAM AND STATE PROJECT AND FINANCIAL ASSISTANCE PROGRAM AND ON INTERNAL CONTROL OVER COMPLIANCE IN ACCORDANCE WITH OMB CIRCULAR A-133 AND CHAPTER , STATE OF FLORIDA RULES OF THE AUDITOR GENERAL SCHEDULE OF FINDINGS AND QUESTIONED COSTS FOR THE YEAR ENDED DECEMBER 31, SUMMARY SCHEDULE OF PRIOR AUDIT FINDINGS 43 INDEPENDENT AUDITORS MANAGEMENT LETTER IN ACCORDANCE WITH THE STATE OF FLORIDA RULES OF THE AUDITOR GENERAL

3 Deloitte & Touche LLP Certified Public Accountants 333 Southeast Second Avenue Suite 3600 Miami, FL USA Tel: Fax: INDEPENDENT AUDITORS REPORT To the Board of Trustees of Mount Sinai Medical Center of Florida, Inc. Miami Beach, Florida We have audited the accompanying consolidated statements of financial position of Mount Sinai Medical Center of Florida, Inc. and subsidiaries (the Medical Center ) as of December 31, 2011 and 2010, and the related consolidated statements of operations and changes in net assets and of cash flows for the years then ended. These consolidated financial statements are the responsibility of the management of the Medical Center. Our responsibility is to express an opinion on these consolidated financial statements based on our audits. We conducted our audits in accordance with auditing standards generally accepted in the United States of America and the standards applicable to financial audits contained in Government Auditing Standards, issued by the Comptroller General of the United States. 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 consideration of internal control over financial reporting as a basis for designing procedures that are appropriate in the circumstances, but not for the purpose of expressing an opinion on the effectiveness of the Medical Center s internal control over financial reporting. Accordingly, we express no such opinion. An audit also 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 the significant estimates made by 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 consolidated financial statements referred to above present fairly, in all material respects, the financial position of the Medical Center as of December 31, 2011 and 2010, and the changes in its net assets and its cash flows for the years then ended in conformity with accounting principles generally accepted in the United States of America. Our audits were conducted for the purpose of forming an opinion on the basic consolidated financial statements of the Medical Center taken as a whole. The accompanying supplemental consolidating information on pages 31 through 33 is presented for the purpose of additional analysis of the basic consolidated financial statements rather than to present the financial position and results of operations of the individual companies, and is not a required part of the basic consolidated financial statements. The accompanying supplemental schedule of expenditures of federal awards and state projects and financial assistance programs are presented for the purpose of additional analysis as required by the U.S. Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Governments, and Non-Profit Organizations, and the State of Florida Rules of the Auditor General, Chapter , State Single Audit Audits of Non-Profit and For-Profit Organizations, and is not a required part of the basic consolidated financial statements. The supplemental information, schedules, and notes are the responsibility of the

4 management of the Medical Center. The supplemental information have been subjected to the auditing procedures applied in our audits of the basic consolidated financial statements and, in our opinion, is fairly stated in all material respects in relation to the basic consolidated financial statements taken as a whole. As discussed in Note 1 to the consolidated financial statements, the accompanying 2010 consolidated financial statements have been retrospectively adjusted for the adoption of Accounting Standards Update , Healthcare Entities: Presentation of Insurance Claims and Related Recoveries. In accordance with Government Auditing Standards, we have also issued our report dated June 25, 2012, on our consideration of the Medical Center s internal control over financial reporting and on our tests of its compliance with certain provisions of laws, regulations, contracts, and grant agreements and other matters. The purpose of that report is to describe the scope of our testing of internal control over financial reporting and compliance and the results of that testing, and not to provide an opinion on the internal control over financial reporting or on compliance. That report is an integral part of an audit performed in accordance with Government Auditing Standards and should be considered in assessing the results of our audit. March 30, 2012 except for financial statements and other information and disclosures performed under the scope of the Office of Management and Budget Circular A-133 and the State of Florida Rules of the Auditor General Chapter which is as of July 6, 2012

5 MOUNT SINAI MEDICAL CENTER OF FLORIDA, INC. AND SUBSIDIARIES CONSOLIDATED BALANCE SHEETS AS OF DECEMBER 31, 2011 AND 2010 (Amounts in thousands) ASSETS CURRENT ASSETS: Cash and cash equivalents $ 17,919 $ 14,211 Temporary investments 156, ,074 Patient accounts receivable net of allowances for uncollectible accounts of approximately $36.1 million in 2011 and $31.7 million in ,160 56,401 Other receivables 1,225 3,352 Inventories 6,460 5,358 Prepaid and other assets 2,476 2,272 Total current assets 245, ,668 ASSETS WHOSE USE IS LIMITED: Funds held by trustee 27,276 27,539 Self-insurance trust fund 93 1,844 Other investments 4,973 6,935 Total assets whose use is limited 32,342 36,318 BENEFICIAL INTEREST IN THE NET ASSETS OF MOUNT SINAI MEDICAL CENTER FOUNDATION, INC. 92,144 87,721 PROPERTY AND EQUIPMENT Net 157, ,638 ASSETS HELD FOR SALE 19,400 - RECEIVABLE FOR INSURED CLAIMS 16,426 13,636 OTHER ASSETS 6,433 6,937 TOTAL $ 570,270 $ 583,918 LIABILITIES AND NET ASSETS CURRENT LIABILITIES: Accounts payable and accrued expenses $ 31,901 $ 32,133 Accrued wages, salaries, and benefits 22,825 21,716 Indigent care assessment current portion 4,282 3,977 Other current liabilities 5,334 7,021 Due to third-party payors 9,700 10,984 Current portion of long-term debt 29,139 8,663 Due to Comprehensive Cancer Centers, Inc. net 2,620 1,635 Total current liabilities 105,801 86,129 LONG-TERM DEBT Net of current portion 233, ,273 INDIGENT CARE ASSESSMENT Net of current portion 2,820 2,815 OTHER LONG-TERM LIABILITIES 1,188 1,693 LIABILITY FOR SELF-INSURED CLAIMS 66,604 60,475 Total liabilities 409, ,385 COMMITMENTS AND CONTINGENCIES (Notes 6, 7, 16, and 19) NET ASSETS: Unrestricted 68,580 86,812 Temporarily restricted 86,474 82,051 Permanently restricted 5,670 5,670 Total net assets 160, ,533 TOTAL $ 570,270 $ 583,918 See notes to consolidated financial statements

6 MOUNT SINAI MEDICAL CENTER OF FLORIDA, INC. AND SUBSIDIARIES CONSOLIDATED STATEMENTS OF OPERATIONS AND CHANGES IN NET ASSETS FOR THE YEARS ENDED DECEMBER 31, 2011 AND 2010 (Amounts in thousands) UNRESTRICTED REVENUES, GAINS, AND OTHER SUPPORT: Net patient service revenue $ 514,935 $ 495,827 Other revenue 20,128 18,951 Contributions from the Foundation 2,500 10,000 Net assets released from temporary restrictions by the Foundation 647 1,227 Net assets released from temporary restrictions for research, grants, and other 3,700 5,316 Total unrestricted revenues, gains, and other support 541, ,321 EXPENSES: Wages, salaries, and benefits 218, ,173 Supplies 80,635 78,361 Administrative and general 56,911 54,067 Malpractice and other insurance net of recoveries 17,048 25,548 Provision for doubtful accounts 56,962 51,476 Depreciation 23,865 22,111 Interest 16,100 16,817 Indigent care assessment 4,887 4,719 Management fees 50,918 45,153 Impairment of long-lived asset 35,436 - Total expenses 561, ,425 (DEFICIENCY) EXCESS OF REVENUES OVER EXPENSES $ (19,570) $ 25,896 (Continued) - 4 -

7 MOUNT SINAI MEDICAL CENTER OF FLORIDA, INC. AND SUBSIDIARIES CONSOLIDATED STATEMENTS OF OPERATIONS AND CHANGES IN NET ASSETS FOR THE YEARS ENDED DECEMBER 31, 2011 AND 2010 (Amounts in thousands) UNRESTRICTED NET ASSETS: (Deficiency) excess of revenues over expenses $ (19,570) $ 25,896 Contributions from Mount Sinai Medical Center Foundation, Inc. for capital expenditures Net assets released from restrictions used for capital purposes 1,338 3,908 (Decrease) increase in unrestricted net assets (18,232) 30,478 TEMPORARILY RESTRICTED NET ASSETS: Temporarily restricted grants and contributions 5,685 10,451 Net assets released from restrictions (5,685) (10,451) Change in the beneficial interest in the net assets of Mount Sinai Medical Center Foundation, Inc. 4,423 (1,540) Increase (decrease) in temporarily restricted net assets 4,423 (1,540) PERMANENTLY RESTRICTED NET ASSETS Change in the beneficial interest in the net assets of Mount Sinai Medical Center Foundation, Inc. - - Change in permanently restricted net assets - - CHANGE IN NET ASSETS (13,809) 28,938 NET ASSETS Beginning of year 174, ,595 NET ASSETS End of year $ 160,724 $ 174,533 See notes to consolidated financial statements. (Concluded) - 5 -

8 MOUNT SINAI MEDICAL CENTER OF FLORIDA, INC. AND SUBSIDIARIES CONSOLIDATED STATEMENTS OF CASH FLOWS FOR THE YEARS ENDED DECEMBER 31, 2011 AND 2010 (Amounts in thousands) CASH FLOWS FROM OPERATING ACTIVITIES: Change in net assets $ (13,809) $ 28,938 Adjustments to reconcile change in net assets to net cash provided by operating activities: Depreciation and amortization 24,117 22,363 Bond discount amortization Provision for doubtful accounts 56,962 51,476 Impairment of long-lived asset 35,436 - Noncash purchase discount (48) (1) Loss (gain) on disposal of property, plant, and equipment 37 (2) Changes in the beneficial interest in the net assets of Mount Sinai Medical Center Foundation, Inc. (4,423) 1,540 Realized gains on sale of securities and change in net unrealized losses on investments Changes in operating assets and liabilities: Increase in patient accounts receivable (61,721) (55,906) Decrease in other receivables 2, (Decrease) increase in due to and from third-party payors (1,284) 4,956 (Increase) decrease in inventories (1,102) 1,376 (Increase) decrease in prepaid and other current assets (204) 102 Decrease in other noncurrent assets Increase in receivable for insured claims (2,790) (2,550) Increase (decrease) in due to Comprehensive Cancer Centers, Inc. 985 (53) Increase in accounts payable and accrued expenses 131 5,581 Increase in accrued wages, salaries, and benefits 1,109 4 Increase in indigent care assessment (Decrease) increase in other current liabilities (1,687) 2,653 (Decrease) increase in other long-term liabilities (505) 928 Increase in liability for self-insured claims 6,129 10,329 Net cash provided by operating activities 40,583 73,536 CASH FLOWS FROM INVESTING ACTIVITIES: Purchases of property and equipment (24,347) (23,940) Purchases of investments (157,392) (151,053) Proceeds from sales and maturities of investments 149,874 86,053 Assets whose use is limited: Purchases of investments (30,507) (23,172) Proceeds from sales of investments 34,144 23,892 Net cash used in investing activities (28,228) (88,220) (Continued) - 6 -

9 MOUNT SINAI MEDICAL CENTER OF FLORIDA, INC. AND SUBSIDIARIES CONSOLIDATED STATEMENTS OF CASH FLOWS FOR THE YEARS ENDED DECEMBER 31, 2011 AND 2010 (Amounts in thousands) CASH FLOWS FROM FINANCING ACTIVITIES: Repayment of long-term debt $ (6,585) $ (6,220) Repayment of notes payable/capital lease (2,062) (1,915) Net cash used in financing activities (8,647) (8,135) NET INCREASE (DECREASE) IN CASH AND CASH EQUIVALENTS 3,708 (22,819) CASH AND CASH EQUIVALENTS Beginning of year 14,211 37,030 CASH AND CASH EQUIVALENTS End of year $ 17,919 $ 14,211 SUPPLEMENTAL DISCLOSURE OF CASH FLOW INFORMATION Cash paid for interest net of amounts capitalized of $1,186 and $998 in 2011 and 2010, respectively, was $16,635 in 2011 and $17,114 in 2010 NONCASH INVESTING AND FINANCING ACTIVITIES: Acquisition of equipment through note payable and capital lease $ 3,767 $ 14,130 Acquisition of equipment through accounts payable and accrued expenses $ 2,898 $ 3,261 See notes to consolidated financial statements. (Concluded) - 7 -

10 MOUNT SINAI MEDICAL CENTER OF FLORIDA, INC. AND SUBSIDIARIES NOTES TO CONSOLIDATED FINANCIAL STATEMENTS AS OF AND FOR THE YEARS ENDED DECEMBER 31, 2011 AND ORGANIZATION AND SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES Organization Mount Sinai Medical Center of Florida, Inc. and subsidiaries (the Medical Center ) is a Florida not-for-profit corporation incorporated in The consolidated financial statements of the Medical Center include the accounts of Mount Sinai Medical Center and its majority-owned and controlled subsidiaries. The Medical Center, located in Miami Beach, Florida, is an acute care teaching and research facility, which operates three campuses and various physician practices. Financial Statement Presentation The consolidated financial statements of the Medical Center include the accounts of the Medical Center and its wholly owned subsidiaries, Mount Sinai Medical Center Auxiliary, and the Mount Sinai Medical Center of Florida Guarantee Corporation, and various corporations that operate physician practices. All intercompany transactions have been eliminated in consolidation. The Medical Center includes all of the net assets of the Mount Sinai Medical Center Foundation, Inc. (the Foundation ) as discussed in Note 2. Use of Estimates The preparation of financial statements in conformity with accounting principles generally accepted in the United States of America (GAAP) requires management to make estimates and assumptions that affect the reported amounts of assets and liabilities and disclosure of contingent assets and liabilities at the date of the financial statements and the reported amounts of revenues and expenses during the reporting period. The Medical Center considers critical accounting policies to be those that require more significant judgments and estimates in the preparation of its consolidated financial statements, including the following: recognition of net patient service revenues; valuation of patient accounts receivables, including contractual allowances and allowances for uncollectible accounts; provisions for losses and expenses related to health care, professional and general liabilities; estimated third-party settlements; and litigation and regulatory liabilities. Management relies on historical experience and on other assumptions believed to be reasonable under the circumstances in making its judgments and estimates. Actual results could differ from those estimates. Subsequent Events In preparing these financial statements and in accordance with Accounting Standards Codification (ASC) 855, Subsequent Events, the Medical Center has evaluated events and transactions for potential recognition or disclosure through May 31, 2012, the date the consolidated financial statements were ready to be issued. Cash and Cash Equivalents Cash and cash equivalents include cash on hand, cash in depository accounts, certificates of deposit, and investments in highly liquid debt instruments with original maturities of three months or less. Valuation of Patient Accounts Receivable The Medical Center reports its patient accounts receivable at their net realizable value. The Medical Center determines the net realizable value of its receivables based on established agreements with third-party payors that provide for payments to the Medical Center at amounts that typically differ from its established rates. For services provided to Medicare and Medicaid beneficiaries, estimated receivables are determined based on the programs guidelines for reimbursement of services that are either paid at prospectively determined rates per diagnosis or retrospectively determined costs. Receivables from other third-party payors are based primarily on contractual agreements that determine reimbursement for services rendered to beneficiaries - 8 -

11 of their plans based on predetermined rates per diagnosis, per diem rates, or discounted fee for service rates. As changes in contract terms and the regulatory environment can significantly affect the valuation of its receivables, the Medical Center closely monitors these items along with historical collection rates to ensure the appropriateness of its receivable valuations. Investments and Assets Whose Use is Limited Investments in equity securities with readily determinable fair values and all debt securities are stated at fair value in the consolidated balance sheets. Investment income or losses (including realized and unrealized gains and losses on investments and interest and dividends) are included in other revenue, unless the income or loss is restricted by donor or law. Alternative investments, which are not readily marketable and are less liquid compared to the Medical Center s other investments, include hedge funds and limited partnerships and are held by the Foundation (see Note 2). These investments may contain elements of both credit and market risk. Such risks could include, but are not limited to, limited liquidity, absence of oversight, dependence upon key individuals, emphasis on speculative investments (both derivatives and nonmarketable investments), and nondisclosure of portfolio composition. The estimated fair value of certain alternative investments is principally based upon valuations performed by the external fund managers. Because alternative investments are not readily marketable, their estimated value is subject to uncertainty and therefore may differ from the value that would have been used had a ready market for such investments existed. Inventories Inventories consist primarily of pharmaceutical, medical, and surgical supplies and are priced at the lower of cost (determined by the first-in, first-out method) or market. Property and Equipment Property and equipment are stated at cost less accumulated depreciation. Donated property and equipment are recorded at fair market value on the date of donation. Depreciation is computed on the straight-line method using estimated useful lives ranging from 3 to 40 years. Expenditures that materially increase values, change capacities, or extend useful lives are capitalized, as are interest costs until the assets are ready for their intended use. Gains and losses on dispositions are recorded in income from operations in the year of disposal. Gifts of long-lived assets, such as land, buildings, or equipment, are reported as unrestricted support and are excluded from the excess of revenues over expenses, unless explicit donor stipulations specify how the donated assets must be used. Gifts of long-lived assets with explicit restrictions that specify how the assets are to be used and gifts of cash or other assets that must be used to acquire long-lived assets are reported as restricted support. Absent explicit donor stipulations about how long those long-lived assets must be maintained, expirations of donor restrictions are reported when the donated or acquired longlived assets are placed in service. Property and equipment are more fully described in Note 6 to the consolidated financial statements. The Medical Center evaluates its long-lived assets for impairment whenever events or changes indicate that their carrying amount may not be recoverable. If circumstances suggest that long-lived assets may be impaired, an assessment of recoverability is performed prior to any write-down of assets. An impairment charge is recorded on those assets for which the estimated fair value is below its carrying amount. The Medical Center recorded an impairment charge of approximately $35.4 million during the year ended December 31, 2011 related to the Miami Heart asset as described more fully in Note 6 to the consolidated financial statements. Bond Issue Costs Unamortized bond issue costs of approximately $4.5 million and $4.8 million as of December 31, 2011 and 2010, respectively, are included in other assets in the accompanying consolidated balance sheets. Bond issue costs incurred in obtaining long-term debt are being amortized - 9 -

12 by a method approximating the interest method over the life of the related debt. Amortization of the bond issue costs is included in interest expense in the accompanying consolidated statements of operations and changes in net assets. Net Patient Service Revenue Net patient service revenue is reported at the estimated net realizable amounts due from patients, third-party payors, and others for services rendered, including estimated retroactive adjustments under reimbursement agreements with third-party payors. Retroactive adjustments are accrued on an estimated basis in the period the related services are rendered and adjusted in future periods as final settlements are determined. Net patient service revenues are more fully described in Note 3 to the consolidated financial statements. Charity Care The Medical Center provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than its established rates. Because the Medical Center does not pursue collection of amounts determined to qualify as charity care, they are not reported in net patient service revenue. Charity care is more fully described in Note 4 to the consolidated financial statements. Donor-Restricted Grants and Contributions Contributions receivable, including unconditional promises to give cash and other assets, are recognized as revenues when the donor s commitment is received. Unconditional promises are recognized at the estimated present value of the future cash flows, net of estimated write-offs. Promises made and collected in the same reporting period are recorded when received in the appropriate net asset category. Promises of noncash assets are recorded at their estimated fair value. Conditional promises are recorded at the estimated fair value when donor stipulations are substantially met and the likelihood of not meeting the remaining conditions are remote. Grants and pledges received with donor restrictions that limit the use of the donated assets are reported as either temporarily or permanently restricted support. When a donor restriction expires, that is, when a stipulated time restriction ends, or purpose restriction is accomplished, restricted net assets are reclassified as unrestricted net assets and reported in the consolidated statements of operations and changes in net assets as net assets released from restrictions. The Foundation was established to raise funds for the benefit of the Medical Center. The Foundation is exempt from income taxes under Section 501(c)(3) of the Internal Revenue Code (IRC). The Foundation holds contributed assets that have restrictions by donors stipulating that these assets be spent for designated purposes at the Medical Center. During 2011 and 2010, the Foundation contributed approximately $600,000 and $1.9 million, respectively, to the Medical Center for reimbursement of expenditures incurred specifically related to temporarily restricted purposes. Of such amounts, approximately $600,000 and $1.2 million, respectively, represent reimbursement for operating expenses, and $0 and $674,000, respectively, represent reimbursement for capital expenditures. In addition to the contributions made by the Foundation in the ordinary course of business, the Foundation contributed $2.5 million and $10.0 million to the Medical Center during fiscal 2011 and 2010, respectively, to assist the Medical Center with its working capital needs. The Foundation has not committed to contribute any funds for the Medical Center s working capital needs for the year ending December 31, (Deficiency) Excess of Revenues over Expenses The consolidated statements of operations and changes in net assets include excess of revenues over expenses. Changes in unrestricted net assets, which are excluded from excess of revenues over expenses, consistent with industry practice, include permanent transfers of assets to and from affiliates for other than goods and services and contributions of long-lived assets (including assets acquired using donor-restricted contributions, where the donor restriction was specific and directed the purposes of acquiring such assets)

13 Self-Insurance Programs The Medical Center is self-insured or retains a portion of the risk for certain health claims, workers compensation claims, and professional liability claims. The provision for estimated self-insured claims is included in insurance expense and includes estimates of the ultimate costs for both asserted and unasserted claims. Self-insurance program costs related to workers compensation and professional liability are more fully described in Notes 8 and 9, respectively, to the consolidated financial statements. Management classifies all health claims as a current liability and all workers compensation and professional liability claims as noncurrent liabilities of the Medical Center. Income Taxes The Medical Center is a not-for-profit corporation and has been recognized as tax exempt pursuant to Section 501(c)(3) of the IRC. The IRC provides for taxation of unrelated business income under certain circumstances. Management has concluded that the Medical Center has no material unrelated business income. The Medical Center follows the provisions of ASC , Income Taxes, and has determined that as of December 31, 2011 and 2010, the Medical Center had no material unrecognized tax benefits. The Medical Center does not expect that unrecognized tax benefits will materially increase within the next twelve months. In the event the Medical Center were to recognize interest and penalties related to uncertain tax positions, it would be recognized in the consolidated financial statements as income tax expense. Tax years from 2007 through 2010 are subject to examination by the federal and state taxing authorities, respectively. There are no income tax examinations currently in process. New Accounting Pronouncements In August 2010, the FASB issued Accounting Standards Update (ASU) , Health Care Entities: Presentation of Insurance Claims and Related Insurance Recoveries ( ASU ). ASU amends ASC , Healthcare Entities Contingencies, to require health care organizations to present insurance claims and insurance recoveries on a gross basis rather than offsetting such amounts against each other for financial presentation. Effective January 1, 2011, the Medical Center adopted the provisions of ASU The Medical Center has elected to apply the provisions of this ASU retrospectively. The adoption of this ASU did not have any material impact on the results of operations of the Medical Center. In August 2010, the FASB issued ASU , Health Care Entities: Measuring Charity Care for Disclosure ( ASU ), addressing the diversity of disclosure and measurement of charity care across the health care industry. ASU amends ASC , Healthcare Entities Revenues Recognition to require the following disclosures in health care organization financial statements: 1) management policy for providing charity care; 2) level of charity care; 3) amount of charity care; and 4) the method for measuring the cost of charity cost. This ASU is effective for fiscal years beginning after December 15, 2010, and as such, the Medical Center has adopted this ASU as of January 1, The adoption of this ASU did not have a material impact on the results of operations, financial condition, and cash flows of the Medical Center. In July 2011, the FASB issued ASU , Presentation and Disclosure of Patient Service Revenue, Provision for Bad Debts, and the Allowance for Doubtful Accounts of Certain Health Care Entities, which provides guidance on the presentation and disclosure of patient service revenue and the related provision for bad debts and allowance for doubtful accounts. The ASU requires entities to present its patient service revenue net of its provision for bad debts instead of showing bad debts as an operating expense in the statement of operations. The guidance provided in this ASU will be effective for fiscal years beginning after December 15, 2011, and as such, the Medical Center has adopted this ASU as of January 1, The adoption of this ASU is not expected to have a material impact on the results of operations, financial condition, and cash flows of the Medical Center

14 2. BENEFICIAL INTEREST IN THE NET ASSETS OF MOUNT SINAI MEDICAL CENTER FOUNDATION, INC. The Medical Center accounts for its interests in the Foundation in accordance with ASC 958, Transfers of Assets to a Not-for-Profit Organization or Charitable Trust That Raises or Holds Contributions for Others. Pursuant to ASC 958, the Medical Center and the Foundation are financially interrelated organizations. Accordingly, the Medical Center is required to recognize its interest in the net assets of the Foundation and adjust that interest for its share of the change in net assets of the Foundation. As of December 31, 2011 and 2010, all of the net assets held by the Foundation were recorded as a noncurrent asset in the consolidated balance sheets of the Medical Center as a beneficial interest in the net assets of the Foundation. The Foundation was established to solicit contributions from the general public solely for the funding of operations and capital acquisitions by the Medical Center. Funds are distributed to the Medical Center as determined by the Foundation s Board of Trustees. The Medical Center periodically requests funds from the Foundation for capital or other needs. Such requests are received by the Foundation and, if approved, funds are transferred to the Medical Center. Such transfers of funds are reported in the accompanying consolidated financial statements as contributions from the Foundation. The Medical Center s beneficial interest in the unrestricted and temporarily restricted net assets of the Foundation and its share of the change in those net assets are reported in the accompanying consolidated financial statements in temporarily restricted net assets. The Medical Center s beneficial interest in permanently restricted net assets of the Foundation and its share of changes therein are reported in the accompanying consolidated financial statements in permanently restricted net assets. The Foundation considers critical accounting policies to be those that require more significant judgments and estimates in the preparation of its financial statements, including the following: recognition of contributions; valuation of accounts receivables, including pledges and receivables under contribution agreements; and valuation of investments. Management relies on historical experience and on other assumptions believed to be reasonable under the circumstances in making its judgments and estimates. Actual results could differ from those estimates

15 A summary of the Foundation s assets, liabilities, net assets, results of operations and changes in net assets as of December 31, 2011 and 2010, is as follows (amounts in thousands): Assets: Cash and cash equivalents $ 5,712 $ 4,684 Pledges receivable net 28,578 29,378 Receivables under contribution agreements net 18,764 13,315 Investments 33,864 35,148 Endowment investment 5,670 5,670 Prepaid expenses and other assets Due from the Medical Center Total assets $ 92,800 $ 88,490 Total liabilities $ 656 $ 769 Net assets: Unrestricted 7,705 6,194 Temporarily restricted 78,769 75,857 Permanently restricted 5,670 5,670 Total net assets 92,144 87,721 Total liabilities and net assets $ 92,800 $ 88,490 Total revenues amounts raised $ 13,556 $ 13,559 Interest, dividends, and other net (A) (670) 2,224 Operating expenses (5,315) (5,422) Transfers to the Medical Center (3,148) (11,901) Increase (decrease) in net assets 4,423 (1,540) Net assets January 1 87,721 89,261 Net assets December 31 $ 92,144 $ 87,721 (A) Interest, dividends, and other net, includes realized and unrealized gains (losses) of $(1.6) million and $1.2 million for the years ended December 31, 2011 and 2010, respectively. As of December 31, 2011, the Foundation s investments and endowment investments consisted of approximately $17.4 million, $14.6 million, and $7.5 million of Level 1, Level 2, and Level 3 investments, respectively. The Foundation s Level 3 investments consist of approximately $5.0 million of financial instruments and $2.5 million of alternative investments, which are accounted for at their estimated fair value. The fair value of the financial instruments, which is mainly comprised of an investment in a donated life insurance policy, was determined using a valuation model based on the present value of the face amount of the policy less the present value of the Foundation s expected future premium payments. The present value model utilized the face value, risk-free rate, and life expectancy of the insured to determine the

16 value of the policy. The Foundation estimated the fair value of its alternative investments, which are held in private hedge funds, using information provided by the fund managers and an internally developed valuation model, which utilizes inputs provided by the fund managers. Additionally, the value of the alternative investments is compared to actual audited financial results, when available. Because alternative investments are not readily marketable, their estimated value is subject to uncertainty and therefore may differ from the value that would have been used had a ready market for such investments existed. Such differences could be material. The Foundation s endowment consists of approximately 50 individual funds established for a variety of purposes. The endowment consists of donor-restricted funds that have been limited by donors to specific time period or purpose. As required by accounting principles generally accepted in the United States of America, net assets associated with endowment funds are classified and reported based on the existence or absence of donor-imposed restrictions. The endowment net asset composition by fund type as of December 31, 2011, is comprised of the following (in thousands): Endowment Net Asset Composition by Fund Type Temporarily Permanently Unrestricted Restricted Restricted Alzheimer s program $ - $ 4,892 $ - Melanoma research - 4,286 - Cancer lifeline - 1,535 - Cancer research - 2,393 - Other programs - 12,616 5,670 Total funds $ - $ 25,722 $ 5, NET PATIENT SERVICE REVENUE The Medical Center has agreements with third-party payors that provide for payments to the Medical Center at amounts different from its established rates. A summary of the payment arrangements with major third-party payors is as follows: Medicare As of October 1, 2007, Medicare changed its reimbursement methodology from Diagnostic Related Groups (DRG) to Medicare Severity Diagnostic Related Groups (MS-DRGs), thus expanding the number of DRGs available for coding patient accounts. Inpatient acute care services rendered to Medicare program beneficiaries are paid at prospectively determined rates per discharge based on MS- DRGs. MS-DRG rates vary based on clinical diagnostic and other factors. Outpatient services rendered to Medicare beneficiaries are paid on a fee schedule under a Prospective Payment System based upon Ambulatory Patient Classification (APC). Under this system, each outpatient encounter could result in the assignment of multiple APC payments. Rehabilitation services rendered to Medicare beneficiaries are paid under prospectively determined rates per discharge based upon assignment to a Case Mix Group (CMG). CMG rates vary based on clinical, diagnostic, and other factors. Management believes that the Medical Center s inpatient rehabilitation facility complies with the Centers for the Medicare and Medicaid Services (CMS) sixty percent rule, whereby sixty percent of its patient population has one of the thirteen conditions as designated by CMS

17 Inpatient psychiatric services are paid using a prospectively determined per diem rate based on a MS-DRG assignment adjusted by patient specific factors such as comorbidity, age, length of stay, and other hospital-specific factors. The Medical Center is still reimbursed for cost reimbursable items, such as direct and indirect medical education, disproportionate share, and bad debts. These are paid at a tentative rate with final settlement determined after submission of annual cost reports by the Medical Center and audits thereof by the Medicare fiscal intermediary. During 2011 and 2010, the Medical Center recorded an increase to Medicare net patient service revenue of approximately $3.9 million and $4.2 million to reflect changes in prior-year reimbursement estimates related to the settlement of outstanding cost reports, liabilities associated with revenue adjustments as a result of audits conducted under the Recovery Audit Contractor Program, and the impact of revaluations on open cost report years. The principal components of the change in estimate associated with the cost report settlements include increased disproportionate share payment qualification levels and an increase in the indirect/direct medical education reimbursement previously recorded. During 2011, there were no cost report settlements. All Medicare cost report years subsequent to fiscal year 2006 remain open and subject to audit. Due to the uncertainty and significant estimates surrounding the ultimate acceptance of such matters by the fiscal intermediaries, management relies on historical experience and other assumptions believed to be reasonable under the circumstances in making its judgments and estimates of third-party balances at year-end. As the Medical Center receives additional information, or as facts and circumstances change with respect to the unsettled cost reporting years, changes in estimate could significantly impact the results of operations of the Medical Center and will be recorded in the period that such determinations are made. In both years 2011 and 2010, approximately 37 % of the Medical Center s gross patient service revenue was for services to Medicare beneficiaries. Medicaid Approximately 8% of the Medical Center s gross patient service revenue for both 2011 and 2010 are derived under the Medicaid program. Inpatient and outpatient services rendered to Medicaid program beneficiaries are reimbursed under a cost reimbursement methodology subject to certain cost and regional limits. The Medical Center is reimbursed at a tentative rate with final settlement determined after submission of annual cost reports by the Medical Center and audits thereof by the Medicaid fiscal intermediary. During 2010, the Medical Center finalized its outstanding audit related to the 1997 cost report with the State of Florida. The settlement of the 1997 cost report included favorable increases to reimbursable capital costs, which increased the net reimbursement due on Medicaid patients for subsequent periods not subject to certain cost and regional limits. The favorable settlement was accounted for as a change in prior year reimbursement estimates and increased 2010 Medicaid net patient revenue by approximately $4.1 million. Changes to policy and regulation in the Medicare and Medicaid programs could have an adverse or positive impact on the Medical Center s operations. Final determination of amounts earned pursuant to the Medicare and Medicaid programs is subject to review by appropriate governmental authorities or their agent. Other Third-Party Payors The Medical Center has also entered into payment agreements with certain commercial insurance carriers, health maintenance organizations, and preferred provider organizations. The basis for payment to the Medical Center under these agreements includes prospectively determined rates per discharge, discounts from established charges, and prospectively determined daily rates. In 2011 and 2010, approximately 43% and 42% of the Medical Center s gross patient service revenue was for services to nongovernmental third-party payors, respectively

18 Net patient service revenue for the years ended December 31, 2011 and 2010, consisted of the following (amounts in thousands): Gross patient service revenue: Medicare $ 788,996 $ 726,987 Managed care 938, ,556 Medicaid 172, ,927 Other 159, ,673 Physician revenues 97,982 87,637 Total 2,157,779 1,952,780 Less discounts and allowances (1,642,844) (1,456,953) Net patient service revenue $ 514,935 $ 495,827 Gross patient service revenue is recorded on the accrual basis in the period in which services are provided at established rates. Contractual adjustments are recorded as deductions from gross patient service revenue to determine net patient service revenue. 4. CHARITY CARE The Medical Center maintains records to identify and monitor the level of charity care it provides. The Medical Center does not pursue collection of amounts determined to qualify as charity care and does not report such amount as revenue. Uninsured patients treated at the Medical Center who have income at or below 400% of the federal poverty level are eligible for charity or large discounts on charges. The federal poverty level is established by the federal government and is based on income and family size. The amounts of gross charges foregone for services identified as charity care were approximately $42.6 million and $39.8 million in 2011 and 2010, respectively. Such services represented approximately 2.0% of the gross charges of the Medical Center in both 2011 and The Medical Center s estimated costs for caring for charity care patients for 2011 and 2010 were approximately $12.0 million and $12.2 million, respectively. These estimated costs of providing charity services are based on the Medical Center s cost accounting system. The Medical Center receives disproportionate share hospital (DSH) payments, which are intended to mitigate the cost of uncompensated care provided to indigent patients. Revenues attributable to DSH payments were approximately $14.3 million and $15.5 million for 2011 and 2010, respectively. The total costs to provide uncompensated care including those patients that qualified for charity care was approximately $17.1 million and $19.2 million for 2011 and 2010, respectively

19 5. TEMPORARY INVESTMENTS AND ASSETS WHOSE USE IS LIMITED Temporary investments and assets whose use is limited at December 31, 2011, are set forth in the following table and stated at fair value: Assets Temporary Investments and Temporary Whose Use Assets Whose Use is Limited Investments is Limited Total Cash and short-term investments $ - $ 25,353 $ 25,353 Long-term certificate of deposits 59,631-59,631 U.S. treasury obligations 81,212-81,212 U.S. agency obligations 3,580 6,761 10,341 Municipal bonds Corporate bonds 5,035-5,035 Agency backed securities Agency mortgaged backed securities 5,538-5,538 Interest receivable Totals $ 156,634 $ 32,342 $ 188,976 Temporary investments and assets whose use is limited at December 31, 2010, are set forth in the following table and stated at fair value: Assets Temporary Investments and Temporary Whose Use Assets Whose Use is Limited Investments is Limited Total Cash and short-term investments $ - $ 27,112 $ 27,112 Long-term certificate of deposits 34,484-34,484 U.S. treasury obligations 113, ,223 U.S. agency obligations 212 7,363 7,575 Corporate bonds 1,074 1,466 2,540 Interest receivable Totals $ 149,074 $ 36,318 $ 185,392 Investment income, including gains and losses for assets whose use is limited, cash and cash equivalents, and investments, is included as a component of other revenue in the consolidated statements of operations and changes in net assets. The components of investment income for the years ended December 31, 2011 and 2010, are comprised of the following (amounts in thousands): Investment income: Interest and dividend income $ 1,947 $ 1,836 Realized gains on sales of securities Net unrealized losses on investments (412) (394) Total $ 1,650 $ 1,

20 6. PROPERTY AND EQUIPMENT Property and equipment as of December 31, 2011 and 2010, are summarized as follows (amounts in thousands): Land and land improvements $ 4,598 $ 21,383 Buildings and improvements 209, ,536 Equipment and software 132, ,707 Equipment under capital lease 21,603 3,707 Total 368, ,333 Less accumulated depreciation (218,683) (270,933) Total 149, ,400 Construction in progress 8,205 22,238 Property and equipment net $ 157,651 $ 208,638 Depreciation expense for the years ended December 31, 2011 and 2010, amounted to approximately $23.9 million and $22.1 million, respectively. The estimated cost to complete construction in progress for 2011 and 2010 is approximately $17.6 million and $43.5 million, respectively. Accumulated depreciation for equipment under capital lease obligation was approximately $4.2 million and $1.3 million as of December 31, 2011 and 2010, respectively. Interest capitalized during fiscal years 2011 and 2010 was approximately $1.1 million and $998,000, respectively. The Medical Center performs an ongoing assessment of property and equipment, which was fully depreciated but still in service. In connection with this assessment, the Medical Center wrote-off approximately $38.6 million and $32.1 million of fully depreciated fixed assets and the related accumulated depreciation in the years ended December 31, 2011 and 2010, respectively. During 2011 and 2010, the Medical Center incurred approximately $1.3 million and $3.9 million, respectively, for capital expenditures incurred in connection with the hurricane preparedness programs, Lowenstein Workforce program, and other grants that are expected to be reimbursed by grantors. Such amounts have been recorded as an increase in unrestricted net assets in the accompanying consolidated statements of operations and changes in net assets for the years ended December 31, 2011 and During April 2010, the Medical Center became fully obligated under an agreement with Epic Systems Corporation ( EPIC ). EPIC is a leading provider of electronic health record solutions for hospitals and physicians. The Medical Center intends to implement the EPIC software suite to provide the clinicians and physicians with electronic access to patient information. The Medical Center expects to realize benefits of improved patient safety, better clinical outcomes, and both employee and patient satisfaction. The total estimated cost to complete the software implementation is approximately $44.3 million and the estimated date of completion is As of December 31, 2011, the Medical Center recorded $600,000 as construction in process related to the software implementation and $32.7 million as equipment and software for the portion of the software implementation that is currently being used by the Medical Center. As a result of this implementation, the Medical Center expects to receive additional stimulus reimbursement funding beginning in 2013, as outlined in the HITECH portion of the American Recovery and Reinvestment Act of An estimate of the additional funding cannot be made at this time

21 On February 8, 2012, the Medical Center completed the sale of the Miami Heart asset to an unrelated third party purchaser. As of December 31, 2011, Management has concluded that the Miami Heart asset has met the criteria for classification as an asset held-for-sale as set forth in ASC 360, Property, Plant and Equipment, and has presented the Miami Heart as such within non-current assets. As of December 31, 2011, the carrying value of the Miami Heart asset exceeded the purchase price per the agreement, and as a result, the Medical Center has recorded an impairment loss of approximately $35.4 million within the consolidated statement of operations and changes in net assets. 7. LONG-TERM DEBT Long-term debt and notes payable as of December 31, 2011 and 2010, consist of the following (amounts in thousands): Hospital Revenue Refunding Bonds, Series 2004 net of original issue discount of $1,814 and $1,916 at December 31, 2011 and 2010, respectively $ 88,636 $ 91,314 Hospital Revenue Bonds, Series 2001A net of original issue discount of $1,259 and $1,321 at December 31, 2011 and 2010, respectively 62,201 65,609 Hospital Revenue Bonds, Series 1998 net of original issue discount of $1,705 and $1,806 at December 31, 2011 and 2010, respectively 94,450 94,684 EPIC License Agreement 3.234% imputed interest rate, note matures in October ,532 7,777 EPIC Implementation Agreement 5.726% imputed interest rate, note matures in October ,639 4,510 Capital lease and notes payable obligations with interest rates between 2.992% and 6.0%, with maturities from August 2013 through December 2016, collateralized by equipment 5,814 3,042 Total long-term debt 262, ,936 Less current portion 29,139 8,663 Long-term debt net of current portion $ 233,133 $ 258,273 On April 28, 2004, the Mount Sinai Medical Center Obligated Group issued, through the City of Miami Beach Health Facilities Authority (the Authority ), $107,075,000 of its Hospital Revenue Refunding Bonds, Series 2004 (the Series 2004 Bonds ). The Series 2004 Bonds were issued as fully registered bonds and bear interest annually at 5.5%, 5.75%, 6%, and 6.125% for each of the four terms, which make up the Series 2004 obligations. Interest is payable semiannually on May 15 and November 15, commencing November 15, The Series 2004 Bonds were issued with the purpose of providing funds, together with other available funds, to (i) refund $24,745,000 of outstanding principal due under the Medical Center s Hospital Revenue Bonds Series 2001 B ( Series 2001B Bonds ) and $69,940,000 of outstanding principal due under the Medical Center s Hospital Revenue Bonds Taxable Series 2001 C ( Series 2001C Bonds ), (ii) fund a deposit to a bond reserve account, and (iii) pay certain expenses in connection with the issuance of the Series 2004 Bonds. The four term bonds that make up the Series 2004 issuance mature on November 15, 2009, 2021, 2024, and 2029, respectively, and have been unconditionally guaranteed by the Foundation pursuant to the amended and restated guarantee and security agreement dated April 1, 2004, between the Foundation and the bond trustee (the Guaranty Agreement )

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