R1 RCM 10-K 18 Feb 21 2020 FY Annual report Financial data

Document and Entity Information

Document and Entity Information - USD ($)	12 Months Ended
	Dec. 31, 2020	Feb. 11, 2021	Jun. 30, 2020
Cover [Abstract]
Document Type	10-K
Document Annual Report	true
Document Period End Date	Dec. 31, 2020
Current Fiscal Year End Date	--12-31
Document Transition Report	false
Entity File Number	001-34746
Entity Registrant Name	R1 RCM Inc.
Entity Incorporation, State or Country Code	DE
Entity Tax Identification Number	02-0698101
Entity Address, Address Line One	401 North Michigan Avenue
Entity Address, City or Town	Chicago
Entity Address, State or Province	IL
Entity Address, Postal Zip Code	60611
City Area Code	312
Local Phone Number	324-7820
Title of 12(b) Security	Common stock, par value $0.01 per share
Trading Symbol	RCM
Security Exchange Name	NASDAQ
Entity Well-known Seasoned Issuer	Yes
Entity Voluntary Filers	No
Entity Current Reporting Status	Yes
Entity Interactive Data Current	Yes
Entity Filer Category	Large Accelerated Filer
Entity Small Business	false
Entity Emerging Growth Company	false
ICFR Auditor Attestation Flag	true
Entity Shell Company	false
Entity Public Float			$ 1,286,428,886
Entity Common Stock, Shares Outstanding (in shares)		261,066,217
Documents Incorporated by Reference	Portions of the registrant’s definitive proxy statement for its 2021 Annual Meeting of Stockholders are incorporated by reference into Part III of this Annual Report on Form 10-K.
Amendment Flag	false
Document Fiscal Year Focus	2020
Document Fiscal Period Focus	FY
Entity Central Index Key	0001472595

Consolidated Balance Sheets

Consolidated Balance Sheets - USD ($) $ in Millions	Dec. 31, 2020	Dec. 31, 2019
Current assets:
Cash and cash equivalents	$ 173.8	$ 92
Accounts receivable, net of $3.7 million and $2.8 million allowance	91.3	52.3
Accounts receivable, net of $0.1 million and $0.0 million allowance - related party	30.9	30.8
Prepaid expenses and other current assets	59.4	41.6
Total current assets	355.4	216.7
Property, equipment and software, net	93.7	116.9
Operating lease right-of-use assets	57.8	77.9
Intangible assets, net	171.1	164.7
Goodwill	375.3	253.2
Non-current deferred tax assets	73.7	64.2
Non-current portion of restricted cash equivalents	1	0.5
Other assets	61	35
Total assets	1,189	929.1
Current liabilities:
Accounts payable	18.2	20.2
Current portion of customer liabilities	16.7	14
Current portion of customer liabilities - related party	15.3	34.1
Accrued compensation and benefits	51.9	95.1
Current portion of operating lease liabilities	12.2	12.8
Current portion of long-term debt	32.3	16.3
Accrued expenses and other current liabilities	59.7	40
Total current liabilities	206.3	232.5
Non-current portion of customer liabilities - related party	16.3	18.6
Non-current portion of operating lease liabilities	71	82.7
Long-term debt	519.7	337.7
Other non-current liabilities	36.3	10.4
Total liabilities	849.6	681.9
8.00% Series A convertible preferred stock, par value $0.01, 370,000 shares authorized, 288,497 shares issued and outstanding as of December 31, 2020 (aggregate liquidation value of $294.3); 370,000 shares authorized, 266,529 shares issued and outstanding as of December 31, 2019 (aggregate liquidation value of $271.9)	251.5	229.1
Stockholders’ equity:
Common stock, $0.01 par value, 500,000,000 shares authorized, 137,812,559 shares issued and 121,144,038 shares outstanding at December 31, 2020; 127,807,546 shares issued and 114,021,280 shares outstanding at December 31, 2019	1.4	1.3
Additional paid-in capital	393.7	372.7
Accumulated deficit	(161.5)	(277.8)
Accumulated other comprehensive loss	(6.5)	(4.5)
Treasury stock, at cost, 16,668,521 shares as of December 31, 2020; 13,786,266 shares as of December 31, 2019	(139.2)	(73.6)
Total stockholders’ equity	87.9	18.1
Total liabilities and stockholders’ equity	$ 1,189	$ 929.1

Consolidated Balance Sheets (Pa

Consolidated Balance Sheets (Parenthetical) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Accounts receivable, allowance	$ 3.7	$ 2.8
Common stock, par value (in dollars per share)	$ 0.01	$ 0.01
Common stock, shares authorized (in shares)	500,000,000	500,000,000
Common stock, shares issued (in shares)	137,812,559	127,807,546
Common stock, shares outstanding (in shares)	121,144,038	114,021,280
Treasury stock, shares (in shares)	16,668,521	13,786,266
Redeemable Convertible Preferred Stock
Preferred stock, dividend rate	8.00%	8.00%
Preferred stock, par value (in dollars per share)	$ 0.01	$ 0.01
Preferred stock, shares authorized (in shares)	370,000	370,000
Preferred stock, shares issued (in shares)	288,497	266,529
Preferred stock, shares outstanding (in shares)	288,497	266,529
Preferred stock, aggregate liquidation value	$ 294.3	$ 271.9
Related Party
Accounts receivable, allowance	$ 0.1	$ 0

Consolidated Statements of Oper

Consolidated Statements of Operations and Comprehensive Income (Loss) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Income Statement [Abstract]
Net services revenue ($809.5 million, $790.4 million and $600.1 million from related party for the year ended December 31, 2020, 2019 and 2018, respectively)	$ 1,270.8	$ 1,186.1	$ 868.5
Operating expenses:
Cost of services	1,021.1	987.8	770.6
Selling, general and administrative	102.4	104.4	97.9
Other	67.3	36.2	30.4
Total operating expenses	1,190.8	1,128.4	898.9
Income (loss) from operations	80	57.7	(30.4)
Gain on business disposition	55.7	0	0
Loss on debt extinguishment	0	(18.8)	0
Net interest expense	(17.3)	(29.1)	(26.3)
Income (loss) before income tax provision (benefit)	118.4	9.8	(56.7)
Income tax provision (benefit)	1.3	(2.2)	(11.4)
Net income (loss)	$ 117.1	$ 12	$ (45.3)
Net income (loss) per common share:
Basic (in dollars per share)	$ 0.41	$ (0.08)	$ (0.60)
Diluted (in dollars per share)	$ 0.33	$ (0.08)	$ (0.60)
Weighted average shares used in calculating net income (loss) per common share:
Basic (in shares)	115,729,645	111,505,993	108,175,159
Diluted (in shares)	174,573,270	111,505,993	108,175,159
Consolidated statements of comprehensive income (loss)
Net income (loss)	$ 117.1	$ 12	$ (45.3)
Other comprehensive loss:
Net change on derivatives designated as cash flow hedges, net of tax	(1.7)	(0.2)	0.5
Foreign currency translation adjustment	(0.3)	(0.8)	(2.4)
Comprehensive income (loss)	115.1	11	(47.2)
Basic:
Net income (loss)	117.1	12	(45.3)
Less dividends on preferred shares	(22.4)	(20.7)	(19.1)
Less income allocated to preferred shareholders	(47.3)	0	0
Net income (loss) available/allocated to common shareholders - basic	47.4	(8.7)	(64.4)
Diluted:
Net income (loss)	117.1	12	(45.3)
Less dividends on preferred shares	(22.4)	(20.7)	(19.1)
Less income allocated to preferred shareholders	(37.7)	0	0
Net income (loss) available/allocated to common shareholders - diluted	$ 57	$ (8.7)	$ (64.4)

Consolidated Statements of Op_2

Consolidated Statements of Operations and Comprehensive Income (Loss) (Parenthetical) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Income Statement [Abstract]
Net services revenue, from related party	$ 809.5	$ 790.4	$ 600.1

Consolidated Statements of Stoc

Consolidated Statements of Stockholders' Equity (Deficit) - USD ($) $ in Millions	Total	Cumulative Effect, Period of Adoption, Adjustment	Cumulative Effect, Period of Adoption, Adjusted Balance	Common Stock	Common StockCumulative Effect, Period of Adoption, Adjusted Balance	Treasury Stock	Treasury StockCumulative Effect, Period of Adoption, Adjusted Balance	Additional Paid-In Capital	Additional Paid-In CapitalCumulative Effect, Period of Adoption, Adjusted Balance	Accumulated Deficit	Accumulated DeficitCumulative Effect, Period of Adoption, Adjustment	Accumulated DeficitCumulative Effect, Period of Adoption, Adjusted Balance	Accumulated other comprehensive (loss)	Accumulated other comprehensive (loss)Cumulative Effect, Period of Adoption, Adjusted Balance
Beginning Balance (in shares) at Dec. 31, 2017				116,650,388		12,240,427
Beginning Balance at Dec. 31, 2017	$ 33.4			$ 1.2		$ (59.6)		$ 337.9		$ (244.5)			$ (1.6)
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Share-based compensation expense	17.4							17.4
Reclassification of equity award	1.3							1.3
Issuance of common stock related to share-based compensation plans (in shares)				323,964
Issuance of common stock and stock warrants (in shares)				4,665,594
Issuance of common stock and stock warrants	$ 19.2							19.2
Exercise of vested stock options (in shares)	1,713,710			1,713,710
Exercise of vested stock options	$ 4.3							4.3
Dividends paid/accrued on preferred stock	(19.1)							(19.1)
Acquisition of treasury stock related to equity award plans (in shares)						(499,069)
Acquisition of treasury stock related to equity award plans	(3)					$ (3)
Forfeitures (in shares)						(72,259)
Net change on derivatives designated as cash flow hedges, net of tax	0.5												0.5
Foreign currency translation adjustment	(2.4)												(2.4)
Net (loss) income	(45.3)									(45.3)
Ending Balance (in shares) at Dec. 31, 2018				123,353,656		12,811,755
Ending Balance at Dec. 31, 2018	6.3			$ 1.2		$ (62.6)		361		(289.8)			(3.5)
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Share-based compensation expense	$ 18.8							18.8
Issuance of common stock related to share-based compensation plans (in shares)				1,812,993
Exercise of vested stock options (in shares)	2,640,897			2,640,897
Exercise of vested stock options	$ 13.7			$ 0.1				13.6
Dividends paid/accrued on preferred stock	(20.7)							(20.7)
Acquisition of treasury stock related to equity award plans (in shares)						(973,303)
Acquisition of treasury stock related to equity award plans	(11)					$ (11)
Forfeitures (in shares)						(1,208)
Net change on derivatives designated as cash flow hedges, net of tax	(0.2)												(0.2)
Foreign currency translation adjustment	(0.8)												(0.8)
Net (loss) income	12									12
Ending Balance (in shares) at Dec. 31, 2019				127,807,546	127,807,546	13,786,266	13,786,266
Ending Balance at Dec. 31, 2019	18.1	$ (0.8)	$ 17.3	$ 1.3	$ 1.3	$ (73.6)	$ (73.6)	372.7	$ 372.7	(277.8)	$ (0.8)	$ (278.6)	(4.5)	$ (4.5)
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Share-based compensation expense	24.2							24.2
Issuance of common stock related to share-based compensation plans (in shares)				6,848,859
Issuance of common stock related to share-based compensation plans	$ 0			$ 0.1				(0.1)
Exercise of vested stock options (in shares)	3,156,154			3,156,154
Exercise of vested stock options	$ 19.3							19.3
Dividends paid/accrued on preferred stock	(22.4)							(22.4)
Acquisition of treasury stock related to equity award plans (in shares)						(2,882,255)
Acquisition of treasury stock related to equity award plans	(65.6)					$ (65.6)
Net change on derivatives designated as cash flow hedges, net of tax	(1.7)												(1.7)
Foreign currency translation adjustment	(0.3)												(0.3)
Net (loss) income	117.1									117.1
Ending Balance (in shares) at Dec. 31, 2020				137,812,559		16,668,521
Ending Balance at Dec. 31, 2020	$ 87.9			$ 1.4		$ (139.2)		$ 393.7		$ (161.5)			$ (6.5)

Consolidated Statements of St_2

Consolidated Statements of Stockholders' Equity (Deficit) (Parenthetical) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Cumulative Effect, Period of Adoption, Adjustment
Impact of credit-loss, standard adoption, tax		$ 0.3
AOCI Attributable to Parent
Net change on derivatives designated as cash flow hedges, tax	$ 0.6	$ 0.1	$ 0.2

Consolidated Statements of Cash

Consolidated Statements of Cash Flows - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Operating activities
Net income (loss)	$ 117.1	$ 12	$ (45.3)
Adjustments to reconcile net income (loss) to net cash provided by operations:
Depreciation and amortization	68.7	55.7	38.8
Amortization of debt issuance costs	1	1.6	1.5
Share-based compensation	24.1	18.6	18.4
Gain on sale of Emergency Medical Services business	(55.7)	0	0
Loss on disposal and right-of-use asset write-downs	17	0.1	0.4
Loss on debt extinguishment	0	18.8	0
Provision for credit losses	0.6	2.9	0.8
Deferred income taxes	(1.2)	(5.1)	(14)
Non-cash lease expense	7.3	11.4	0
Change in value of contingent consideration	4.7	0	0
Changes in operating assets and liabilities:
Accounts receivable and related party accounts receivable	(56.5)	11.5	(39.1)
Prepaid expenses and other assets	(12.9)	(17.9)	(17)
Accounts payable	(3.4)	9.9	(3)
Accrued compensation and benefits	(40.3)	18.2	31.9
Lease liabilities	(13.6)	(11.8)	0
Other liabilities	25.3	4.8	9.8
Customer liabilities and customer liabilities - related party	(20.4)	(16.8)	35.1
Net cash provided by operating activities	61.8	113.9	18.3
Investing activities
Purchases of property, equipment, and software	(49.3)	(61)	(33.5)
Acquisition of SCI, net of cash acquired and earn-out provision	(191)	0	0
Acquisition of RevWorks, net of contingent consideration	(5)	0	0
Acquisition of Intermedix Holdings, Inc., net of cash acquired	0	0	(462.8)
Proceeds from sale of Emergency Medical Services business, net of cash disposed	128.3	0	0
Net cash used in investing activities	(117)	(61)	(496.3)
Financing activities
Issuance of subordinated notes, net of discount and issuance costs	0	0	105.5
Repayment of senior secured debt and revolver	(23.4)	(276.8)	(1.3)
Repayment of subordinated notes and prepayment penalty	0	(112.2)	0
Issuance of common stock and stock warrants, net of issuance costs	0	0	19.2
Exercise of vested stock options	18.4	13.7	4.3
Shares withheld for taxes	(71.9)	(11)	(3)
Finance lease payments	(0.8)	(0.8)	0
Other	(5)	0	0
Net cash provided by (used in) financing activities	137.9	(25.3)	377.4
Effect of exchange rate changes in cash	(0.4)	(0.2)	(0.7)
Net increase (decrease) in cash, cash equivalents, and restricted cash	82.3	27.4	(101.3)
Cash, cash equivalents, and restricted cash at beginning of period	92.5	65.1	166.4
Cash, cash equivalents, and restricted cash at end of period	174.8	92.5	65.1
Supplemental disclosures of cash flow information
Accrued dividends payable to Preferred Stockholders	5.8	5.3	4.9
Accrued and other liabilities related to purchases of property, equipment and software	8.1	20.6	19.6
Accounts payable related to purchases of property, equipment and software	2.9	1.2	0.9
Interest paid	15.8	26.5	23.4
Income taxes paid	4.2	4	3.3
Income taxes refunded	0.4	0.2	0.5
Senior Term Loan
Financing activities
Issuance of senior secured debt, net of discount and issuance costs and borrowings on revolver	190.6	321.8	253.1
Senior Revolver
Financing activities
Issuance of senior secured debt, net of discount and issuance costs and borrowings on revolver	50	60	0
Repayment of senior secured debt and revolver	(20)	(20)	0
Senior Revolver | Line of Credit
Financing activities
Payment of debt issuance costs related to the Senior Revolver	$ 0	$ 0	$ (0.4)

Description of Business

Description of Business	12 Months Ended
	Dec. 31, 2020
Organization, Consolidation and Presentation of Financial Statements [Abstract]
Description of Business	Description of Business R1 RCM Inc. (the “Company”) is a leading provider of technology-driven solutions that transform the patient experience and financial performance of healthcare providers. The Company helps healthcare providers generate sustainable improvements in their operating margins and cash flows while also enhancing patient, physician, and staff satisfaction for its customers. The Company achieves these results for its customers by managing healthcare providers’ revenue cycle operations, which encompass processes including patient registration, insurance and benefit verification, medical treatment documentation and coding, bill preparation, and collections from patients and payers. The Company does so by deploying a unique operating model that leverages its extensive healthcare site experience, innovative technology, and process excellence. The Company assists its Revenue Cycle Management (“RCM”) customers in managing their revenue cycle operating costs while simultaneously increasing the portion of the maximum potential services revenue they receive. Together, these benefits can generate significant and sustainable improvements in operating margins and cash flows for the Company's customers. The Company's primary service offering consists of end-to-end RCM services for health systems, hospitals, and physician groups, which the Company deploys through an operating partner relationship or a co-managed relationship. Under an operating partner relationship, the Company provides comprehensive revenue cycle infrastructure to providers, including all revenue cycle personnel, technology solutions, and process workflow. Under a co-managed relationship, the Company leverages its customers’ existing RCM staff and processes, and supplement them with the Company's infused management, subject matter specialists, proprietary technology solutions, and other resources. Under the operating partner model, the Company records higher revenue and expenses due to the fact that almost all of the revenue cycle personnel are employees of the Company and more third-party vendor contracts are controlled by the Company. Under the co-managed model, the majority of the revenue cycle personnel and more third-party vendor contracts remain with the customer and those costs are netted against the Company's co-managed revenue. For the years ended December 31, 2020, 2019, and 2018, substantially all of the Company's net operating and incentive fees from end-to-end RCM services were generated under the operating partner model. The Company also offers modular services, allowing customers to engage the Company for only specific components of its end-to-end RCM service offering, such as physician advisory services (“PAS”), practice management (“PM”), revenue integrity services (“RIS”), patient experience (“PX”), coding management, and business office. The Company's PAS offering assists healthcare organizations in complying with payer requirements regarding whether to classify a hospital visit as an in-patient or an out-patient observation case for billing purposes. The Company's PM services offer administrative and operational support to allow healthcare providers to focus on delivering high quality patient care and outsource non-core functions to the Company. The Company's RIS offering includes charge capture, charge description master (“CDM”) maintenance, and pricing services that help providers ensure they are capturing the maximum net compliant revenue for services delivered. The Company's PX offering helps patients manage their data in one easy-to-use environment, enabling eligibility validation and insurance plan attribution, demographic accuracy, meeting authorization and referral requirements, medical necessity validation, and patient out-of-pocket cost estimation. The Company's coding management offering drives performance, quality, and consistent results via business intelligence and analysis, human capital management, an accountability framework, and a quality management program. The Company's business office service can help providers with the entire billing function or to specifically recoup revenue that may otherwise be lost by focusing skilled resources in lower priority areas with significant revenue potential. Once implemented, the Company's technology solutions, processes and services are deeply embedded in its customers’ day-to-day revenue cycle operations. The Company believes its service offerings are adaptable to meet an evolving healthcare regulatory environment, technology standards and market trends. Ascension On February 16, 2016, the Company entered into a long-term strategic partnership with Ascension Health Alliance, the parent of the Company's largest customer and the nation’s largest Catholic and non-profit health system, and TowerBrook Capital Partners (“TowerBrook”), an investment management firm (the “Transaction”). As part of the Transaction, the Company amended and restated its Master Professional Services Agreement (“A&R MPSA”) with Ascension Health (“Ascension”) effective February 16, 2016 with a term of ten years. Pursuant to the A&R MPSA and with certain limited exceptions, the Company is the exclusive provider of RCM services and PAS with respect to acute care services provided by the hospitals affiliated with Ascension that execute supplement agreements with the Company. SCI Solutions, Inc. Acquisition On April 1, 2020, the Company completed the acquisition of scheduling.com, Inc. d/b/a SCI Solutions, Inc. (“SCI”) pursuant to a stock purchase agreement dated as of January 9, 2020 (the “Stock Purchase Agreement”), by and among the Company, Clearsight Intermediate Holdings, Inc. (“Clearsight Holdings”) and Clearsight Group Holdings, LLC (the “Seller”) (the “SCI Acquisition”). At the closing of the transaction, the Company purchased from the Seller all of the issued and outstanding equity interests of Clearsight Holdings, which owns all of the issued and outstanding equity interests of SCI. SCI is a leading provider of software-as-a-service (“SaaS”)-based scheduling and patient access solutions. SCI’s platform streamlines the patient and provider experience, creating efficient care networks where health systems’ capacity is digitally and conveniently accessible to all market constituents. The combination of R1 and SCI is expected to deliver enhanced value for healthcare providers by enabling them to expand digital front door strategies for their patients, improve operating efficiency, and increase capacity utilization, among other benefits. Refer to Note 5, Acquisitions for additional details. RevWorks Acquisition On August 3, 2020, the Company completed the acquisition of the RevWorks services business pursuant to an asset purchase agreement dated as of June 2, 2020 (the “RevWorks Purchase Agreement”) by and among the Company and Cerner Corporation (the “RevWorks Acquisition”). At the closing of the transaction, the Company purchased certain assets relating to the RevWorks services business, as specified in the RevWorks Purchase Agreement. The combination of R1 and RevWorks is expected to provide enhanced revenue cycle capabilities and expertise to RevWorks clients, helping drive sustainable financial improvements for providers while improving their patients’ overall experience. Refer to Note 5, Acquisitions for additional details. EMS Disposition

Summary of Significant Accounti

Summary of Significant Accounting Policies	12 Months Ended
	Dec. 31, 2020
Accounting Policies [Abstract]
Summary of Significant Accounting Policies	Summary of Significant Accounting Policies Basis of Presentation The consolidated financial statements include the assets, liabilities and results of operations of the Company and its wholly owned subsidiaries. All material intercompany transactions and balances have been eliminated in consolidation. The preparation of financial statements in conformity with the United States generally accepted accounting principles (“GAAP”) requires management to make estimates and assumptions that affect the amounts reported in these consolidated financial statements and accompanying notes. Actual results can differ from those estimates. Segments Reporting segments are identified as components of an enterprise about which separate discrete financial information is available and is evaluated by the chief operating decision maker, or decision-making group, relating to resource allocation and performance assessments. All of the Company’s significant operations are organized around the single business of providing revenue cycle operations for healthcare providers. The Company views its operations and manages its business as one operating and reportable segment. Revenue Recognition The Company's primary source of revenue is its end-to-end RCM services fees. The Company also generates revenue through modular RCM services, where customers will engage the Company for only specific components of its end-to-end RCM service offering on a fixed-fee or transactional basis. Revenue Cycle Management RCM services fees are primarily variable and performance related, and are generally viewed as the consideration earned in satisfaction of a single performance obligation which is considered a series. Variable consideration for end-to-end RCM services are allocated to and recognized over the related time period as the amounts reflect the consideration the Company is entitled to and relate specifically to the Company’s efforts to satisfy its performance obligation. Fees for physician group RCM services include variable consideration contingent on customer collections, and inputs to the Company’s revenue estimates typically include historical service fees and historical customer collection amounts. RCM services fees consist of net operating fees, incentive fees, and other fees. Net Operating Fees The Company’s net operating fees consist of: i) gross base fees invoiced to customers; less ii) corresponding costs of customers’ revenue cycle operations which the Company pays pursuant to its RCM agreements, including salaries and benefits for the customers' RCM personnel, and related third-party vendor costs; plus iii) fees accrued for physician group RCM services. The Company recognizes revenue related to net operating fees ratably as the performance obligation for the RCM services is satisfied. Base fees are typically billed in advance of the quarter and paid in three monthly payments as the entity performs and the customer simultaneously receives and consumes the benefits of the services provided. The costs of customers’ revenue cycle operations, which the Company pays pursuant to its RCM agreements, are accrued based on the service period. Net operating fees for physician groups are invoiced on a monthly basis and payment terms are typically 30 days. Incentive Fees Incentive fees are structured to reflect quarterly or annual performance and are evaluated on a contract-by-contract basis. The Company estimates incentive fee revenue based on contractually agreed-upon financial or operating metrics. The Company recognizes revenue related to incentive fees ratably as the performance obligation for RCM services is satisfied, to the extent that it is probable that a significant reversal of cumulative revenue will not occur once the uncertainty is resolved. Incentive fees are typically billed and paid on a quarterly basis. Other The Company recognizes revenue related to other RCM fees as RCM services are provided. These services consist of an obligation to provide a specific component of its end-to-end RCM service offering. Fees are typically variable in nature with the entire amount being included in revenue in the month of service. The customer simultaneously receives and consumes the benefits provided by the services and the fees are typically billed on a monthly basis and payment terms are typically 30 days. To the extent that certain service fees are fixed and not subject to refund, adjustment, or concession, these fees are generally recognized into revenue ratably as the performance obligation is satisfied. The Company recognizes revenue from PAS in the period in which the service is performed. The Company’s PAS arrangements typically consist of an obligation to provide specific services to customers on an if and when needed basis. These services are provided under a fixed price per unit arrangement. Fees for the Company's PAS arrangements are typically billed on a monthly basis with 30 to 60 day payment terms. PM services arrangements include a single performance obligation, constituting a series, to manage and administer various non-clinical aspects of a customer's physician practice, which may be comprised of numerous physical office locations. Consideration for PM services is typically variable in nature and allocated to and recognized over the related time period as the amounts reflect the consideration the Company is entitled to and relate specifically to the Company’s effort to satisfy its performance obligation. PM services fees are invoiced on a monthly basis and payment terms are typically 30 days. Bundled Services Modular RCM services may be sold separately or bundled in a contract. End-to-end RCM services are typically sold separately but may be bundled with PAS. PAS are commonly sold separately. The typical length of an end-to-end RCM contract is two one For bundled arrangements, the Company accounts for individual services as a separate performance obligation if a service is separately identifiable from other items in the bundled arrangement and if a customer can benefit from it on its own or with other resources that are readily available to the customer. The transaction price is allocated between separate services in a bundle based on their relative standalone selling prices. The standalone selling prices are determined based on the prices at which the Company separately sells its modular services. PAS are provided at a customer’s election but do not represent material rights as the services are priced at standalone selling price throughout the life of the agreement. Cost of Services Costs associated with generating the Company’s net services revenue, including the cost of operating its global business services centers, are expensed as incurred, with the exception of deferred contract costs, which are discussed further in Note 22. Cost of services consist of (i) on-site personnel and technology costs, (ii) global business services costs, and (iii) other costs. On-site personnel and technology costs consist primarily of wages, bonuses, benefits, share-based compensation, travel, and other costs associated with employees who are assigned to customer sites to help manage the Company’s customers’ revenue cycle operations. The other significant portion of such expenses is an allocation of the costs associated with maintaining, improving, and deploying our integrated proprietary technology suite. Global business services costs relate to the Company’s global business services centers in the U.S. and internationally that perform patient scheduling and pre-registration, medical transcription, cash posting, reconciliation of payments to billing records, patient follow-up, and Medicaid eligibility determination for our customers. The Company incurs expenses related to salaries and benefits for employees in its global business services centers and non-payroll costs associated with operating its global business services centers. Other expenses consist of costs related to managing other services. These expenses consist primarily of wages, bonuses, benefits, share-based compensation, and facilities costs. Comprehensive Income (Loss) Comprehensive income (loss) is the net income (loss) of the Company combined with other changes in stockholders’ equity (deficit) not involving ownership interest changes. For the Company, such changes are foreign currency translation adjustments and changes in derivatives designated as cash flow hedges. Cash and Cash Equivalents The Company considers all highly liquid investments with a maturity of three months or less when purchased to be cash equivalents. Restricted Cash Equivalents In 2020 and 2019, restricted cash equivalents represent the amount of cash or certificate of deposits (“CDs”) that the Company is unable to access for operational purposes as it collateralizes certain Company expenses or derivatives. Accounts Receivable and Allowance for Credit Losses Accounts receivable is comprised of unpaid balances pertaining to modular services and end-to-end RCM services, net receivable balances for end-to-end RCM customers after considering cost reimbursements owed to such customers, including related accrued balances, and amounts due from physician RCM and practice management customers. The Company evaluates its accounts receivable for expected credit losses quarterly. The Company maintains an estimated allowance for credit losses to reduce its accounts receivable to the amount that it believes will be collected. This allowance is based on the Company’s historical experience, its assessment of each customer’s ability to pay, the length of time a balance has been outstanding, input from key Company resources assigned to each customer, the status of any ongoing operations with each applicable customer, and environmental factors such as significant shifts in the healthcare environment which the Company believes may have impacted or will impact its customers’ financial health and ability to pay. Property, Equipment and Software Property, equipment and software are stated at cost, and related depreciation and amortization are calculated on the straight-line method over the estimated useful lives of the assets. The Company capitalizes qualifying internal and third-party costs and hardware and software costs related to the Company’s software development activities in accordance with ASC 350-40. The Company amortizes the capitalized software development costs over their estimated life on a straight-line basis. The major classifications of property, equipment and software and their expected useful lives are as follows: Buildings and land 30 to 42 years and indefinite Computers and other equipment 3 to 5 years Leasehold improvements Shorter of 10 years or lease term Office furniture 5 years Software 3 to 5 years Goodwill Goodwill represents the difference between the purchase price of acquired companies and the related fair value of the net assets acquired, which is accounted for by the acquisition method of accounting. The Company annually tests goodwill for impairment on the first day of its fiscal fourth quarter, or more frequently if an event occurs or circumstances change that would more likely than not reduce the fair value below its carrying value. The goodwill impairment test consists of a qualitative assessment of impairment indicators, followed by, if necessary, a quantitative assessment comparing the carrying amount to the reporting unit's fair value. To the extent that the carrying value exceeds the fair value, and impairment charge would be recorded. The Company has determined there to be one reporting unit, consistent with its single operating and reportable segment. As part of its annual impairment analysis, the Company performed a qualitative assessment and determined there was no impairment of goodwill for the year ended December 31, 2020. Impairment of Long-Lived Assets Property, equipment, software, right-of-use (“ROU”) assets, deferred contract costs, and other acquired intangible assets are reviewed for impairment whenever events or changes in circumstances indicate that the carrying amount of the asset may not be recoverable. If circumstances require a long-lived asset or asset group be reviewed for possible impairment, the Company first compares undiscounted cash flows expected to be generated by each asset or asset group to its carrying value. If the carrying value of the long-lived asset or asset group is not recoverable on an undiscounted cash flow basis, an impairment charge is recognized to the extent that the carrying value exceeds the fair value. There was no material impairment of property, equipment, software, deferred contract costs, or other acquired intangible assets for the years ended December 31, 2020, 2019, and 2018. For the year ended December 31, 2020, we impaired ROU assets related to leased facilities which we exited. See Note 16. Other for more information. For the year ended December 31, 2019, there was no material impairment of ROU assets. Accrued Compensation and Benefits Accrued compensation and benefits consists of accrued payroll, bonus, paid time off, health benefits, severance, and compensation and benefits related taxes. Deferred FICA taxes are split between accrued compensation and benefits and other non-current liabilities based on their due date. Income Taxes Income taxes are accounted for under the asset and liability method. Deferred tax assets and liabilities are recognized for the future tax consequences attributable to differences between the financial statement carrying amounts of existing assets and liabilities and their respective tax basis and operating loss and tax credit carry forwards. Deferred tax assets and liabilities are measured using current tax laws and enacted tax rates in effect for the years in which those temporary differences are expected to be recovered or settled. The effect on deferred tax assets and liabilities of a change in tax rates is recognized in income in the period that includes the enactment date. The Company records a valuation allowance for deferred tax assets if, based upon the weight of all available evidence, both positive and negative, it is more likely than not that some or all of the deferred tax assets will not be realized. The Company recognizes the tax benefit from an uncertain tax position only if it is more likely than not that the tax position will be sustained upon examination by the relevant tax authorities, based on the technical merits of the position. The tax benefits recognized in the consolidated financial statements from such a position are measured based on the largest amount of benefit that has a greater than 50% percent likelihood of being realized upon ultimate settlement. Interest and penalties relating to income taxes are recognized in our income tax provision in the consolidated statements of operations and comprehensive income (loss). Legal and Other Contingencies In the normal course of business, the Company is subject to regulatory investigations or legal proceedings, as well as demands, claims and threatened litigation. The Company records an estimated loss for any claim, lawsuit, investigation or proceeding when it is probable that a liability has been incurred and the amount of the loss can be reasonably estimated. Significant judgment is required in both the determination of the probability and whether the loss can be reasonably estimated. Actual expenses could differ from such estimates. Foreign Currency Translation and Transaction Gains (Losses) Assets and liabilities of non-U.S. subsidiaries that operate in a local currency environment, where such local currency is the functional currency, are translated to U.S. dollars at exchange rates in effect at the balance sheet date. Income and expense accounts are translated at average exchange rates during the year which approximates the rates in effect at the transaction dates. The resulting translation adjustments are recorded as a separate component of accumulated other comprehensive income (loss). Share-Based Compensation Expense The Company determines the expense for all employee share-based compensation awards by estimating their fair value and recognizing such value as an expense, on a ratable basis, in the consolidated financial statements over the requisite service period in which the employees earn the awards. Performance based stock awards are recognized in expense when the performance metrics are probable to be achieved. Changes in the estimate of achievement of the performance metrics are recognized in the period of the change through a cumulative catch-up. The Company assesses the performance metrics in its awards on a quarterly basis to determine if a cumulative catch-up is necessary. The fair value of stock options is calculated using the Black-Scholes option pricing model and, for market condition stock awards, the fair value is estimated using Monte Carlo simulations. To determine the fair value of a share-based award using the Black-Scholes option pricing model, the Company makes assumptions regarding the risk-free interest rate, expected future volatility and expected life of the award. These inputs are subjective and generally require significant analysis and judgment to develop. The Company aggregates all employees into one pool based on the grant date for valuation purposes. The risk-free rate is based on the U.S. treasury yield curve in effect at the time of grant. The Company estimates the expected volatility of the share price by reviewing the historical volatility levels of its common stock in conjunction with that of public companies that operate in similar industries or are similar in terms of stage of development or size and then projecting this information toward its future expected volatility. The Company exercises judgment in selecting these companies, as well as in evaluating the available historical and implied volatility for these companies. The Company calculates the expected term in years for each stock option using a simplified method based on the average of each option’s vesting term and original contractual term. The simplified method was used due to the lack of sufficient historical data available to provide a reasonable basis upon which to estimate the expected term of each stock option. To determine the fair value of a share-based award using Monte Carlo simulations, the Company makes assumptions regarding the risk-free interest rate, expected future volatility, expected dividend yield and performance period. The risk-free rate is based on the U.S. treasury yield curve in effect at the time of grant. The Company estimates the expected volatility of the share price by reviewing the historical volatility levels of its common stock in conjunction with that of public companies that operate in similar industries or are similar in terms of stage of development or size and then projecting this information toward its future expected volatility. Dividend yield is determined based on the Company’s future plans to pay dividends. The Company had no plans to pay dividends at December 31, 2020. The Company calculates the performance period based on the specific market condition to be achieved and derived from historical data and estimates of future performance. The Company recognizes compensation expense using a straight-line method over the applicable service or performance period. During each quarter, the share-based compensation expense is adjusted to reflect forfeitures during the period; however, compensation expense already recognized is not adjusted if market conditions are not met. Derivative Financial Instruments The Company is actively managing the risk of changes in foreign currency exchange rates and change in interest rates through foreign currency forward contracts and interest rate swap contracts traded in over-the-counter markets governed by International Swaps and Derivatives Association, Inc. (ISDA) agreements. Derivative transactions are governed by a uniform set of policies and procedures covering areas such as authorization, counterparty exposure and hedging practices. Positions are monitored using techniques such as market value and sensitivity analyses. The Company does not enter into derivative transactions for trading purposes. In order for a derivative to qualify for hedge accounting, the derivative must be formally designated as a cash flow hedge by documenting the relationship between the derivative and the hedged item. The documentation includes a description of the hedging instrument, the hedged item, the risk being hedged, the Company’s risk management objective and strategy for undertaking the hedge, and the method for assessing the effectiveness of the hedge. Additionally, the hedge relationship must be expected to be highly effective at offsetting changes in the cash flows of the hedged item at both inception of the hedge and on an ongoing basis. Prospective and retrospective hedge effectiveness will be assessed by a comparison of the critical terms of the hedging instrument and the hedged transaction. In the event that the Company’s ongoing assessment demonstrates that the critical terms of the hedging instrument or the hedged transaction have changed and no longer match, hedge effectiveness is assessed by use of a Hypothetical Derivative Method, which assesses hedge effectiveness based on a comparison of the change in fair value of the actual derivative designated as the hedging instrument and the change in fair value of a perfectly effective hypothetical derivative. The perfectly effective hypothetical derivative would have terms that identically match the critical terms of the hedged item. The Company’s derivative financial instruments consist of non-deliverable foreign currency forward contracts and interest rate swaps. Fair values for derivative financial instruments are based on prices computed using third-party valuation models and are classified as Level 2 in accordance with the three-level hierarchy of fair value measurements. The change in fair value of a hedging instrument is recorded in accumulated other comprehensive loss as a separate component of stockholders’ equity and is reclassified into either cost of services or interest expense in the consolidated statement of operations and comprehensive income (loss) during the period in which the hedged transaction impacts earnings. Treasury Stock The Company records treasury stock at the cost to acquire such shares, including commissions paid to brokers. Treasury stock is included as a component of stockholders’ equity. Earnings (Loss) Per Share Basic net income per share is computed by dividing net income, less any dividends, accretion or decretion, redemption or induced conversion on the Preferred Stock, by the weighted average number of common shares outstanding during the period. As the Preferred Stock (as defined in Note 14) participates in dividends alongside the Company’s common stock (per their participating dividends), the Preferred Stock would constitute participating securities under ASC 260-10 and are applied to earnings per share using the two-class method. Under this method, all earnings (distributed and undistributed) are allocated to common shares and participating securities based on their respective rights to receive dividends. Diluted net income per share is calculated using the more dilutive of the if-converted or the two-class method. For the year ended December 31, 2020 and 2019, the two-class method was more dilutive and was computed by adjusting the denominator used in the basic net income per share computation by potentially dilutive securities outstanding during the period plus, when their effect is dilutive, incremental shares consisting of shares subject to stock options, shares issuable upon vesting of restricted stock awards (“RSAs”), restricted stock units (“RSUs”), performance-based restricted stock units (“PBRSUs”), and shares issuable upon conversion of preferred stock.

Recent Accounting Pronouncement

Recent Accounting Pronouncements	12 Months Ended
	Dec. 31, 2020
Accounting Policies [Abstract]
Recent Accounting Pronouncements	Recent Accounting Pronouncements Recently Issued Accounting Standards and DisclosuresIn June 2016, the FASB issued ASU 2016-13, Financial Instruments - Credit Losses (Topic 326): Measurement of Credit Losses on Financial Instruments (“ASU 2016-13”). ASU 2016-13 replaces the existing incurred loss impairment model with an expected loss model which requires the use of forward-looking information to calculate credit loss estimates. The change will result in earlier recognition of credit losses. The Company adopted ASU 2016-13 effective January 1, 2020 utilizing a modified retrospective transition method. Adoption of the new standard resulted in the recording of additional allowance for credit losses of $1.1 million and a corresponding impact to retained earnings and deferred tax assets.

Fair Value of Financial Instrum

Fair Value of Financial Instruments	12 Months Ended
	Dec. 31, 2020
Fair Value Disclosures [Abstract]
Fair Value of Financial Instruments	Fair Value of Financial InstrumentsThe Company records its financial assets and liabilities at fair value. The accounting standard for fair value (i) defines fair value as the price that would be received to sell an asset or paid to transfer a liability (an exit price) in an orderly transaction between market participants at the measurement date, (ii) establishes a framework for measuring fair value, (iii) establishes a hierarchy of fair value measurements based upon the ability to observe inputs used to value assets and liabilities, (iv) requires consideration of nonperformance risk and (v) expands disclosures about the methods used to measure fair value. The accounting standard establishes a three-level hierarchy of measurements based upon the reliability of observable and unobservable inputs used to arrive at fair value. Observable inputs are independent market data, while unobservable inputs reflect the Company’s assumptions about valuation. The three levels of the hierarchy are defined as follows: • Level 1: Observable inputs such as quoted prices in active markets for identical assets and liabilities; • Level 2: Inputs other than quoted prices that are observable for the asset or liability, either directly or indirectly. These include quoted prices for similar assets or liabilities in active markets and quoted prices for identical or similar assets or liabilities in markets that are not active, and model-derived valuations in which all significant inputs and significant value drivers are observable in active markets; and • Level 3: Valuations derived from valuation techniques in which one or more significant inputs or significant value drivers are unobservable. The carrying amounts of the Company’s financial instruments, which include financial assets such as cash and cash equivalents, restricted cash equivalents, accounts receivable, net, and certain other current assets, as well as financial liabilities such as accounts payable, accrued service costs, accrued compensation and benefits and certain other accrued expenses, approximate their fair values, due to the short-term nature of these instruments. See Note 24, Derivative Financial Instruments, for a discussion of the fair value of the Company's forward currency derivative contracts and interest rate swaps. The Company believes the carrying value of the senior revolver and term loan (see Note 13, Debt) approximates fair value as they are variable rate bank debt.

Acquisitions

Acquisitions	12 Months Ended
	Dec. 31, 2020
Business Combinations [Abstract]
Acquisitions	Acquisitions SCI On April 1, 2020, the Company completed the acquisition of SCI. The SCI Acquisition has been accounted for under ASC 805, Business Combinations. Accordingly, the accounts of the acquired company, after adjustments to reflect fair values assigned to assets and liabilities, have been included in the Company’s consolidated financial statements since the date of the SCI Acquisition. The purchase price for the SCI Acquisition was $190.0 million, subject to customary adjustments for cash, transaction expenses, earn-out consideration, and normalized working capital. The Company funded the purchase price for the SCI Acquisition and the Company’s associated transaction expenses with a combination of cash on hand and the incurrence of additional indebtedness (see Note 13, Debt). The purchase price has been provisionally allocated, on a preliminary basis, to assets acquired and liabilities assumed based on their established fair values as of the acquisition date. The fair value estimate of assets acquired and liabilities assumed is pending the finalization of deferred tax assets and liabilities. Accordingly, there could be adjustments to the consolidated financial statements, including changes to goodwill although these are not currently expected to be material. The fair value of assets acquired and liabilities assumed is (in millions): Purchase Price Allocation Total purchase consideration $ 196.7 Allocation of consideration to assets acquired and liabilities assumed: Cash and cash equivalents $ 2.9 Accounts receivable 2.8 Prepaid expenses and other current assets 1.1 Property, equipment and software 0.3 Operating lease right-of-use assets 1.2 Intangible assets 86.1 Goodwill 125.6 Accounts payable (0.2) Current portion of customer liabilities (4.0) Accrued compensation and benefits (1.6) Current portion of operating lease liabilities (0.5) Other accrued expenses (0.4) Non-current portion of operating lease liabilities (0.7) Other non-current liabilities (5.0) Deferred income tax liabilities (10.9) Net assets acquired $ 196.7 Other non-current liabilities contained a note payable for $5 million. The Company repaid this note in the second quarter of 2020. The goodwill recognized is primarily attributable to synergies that are expected to be achieved from the integration of SCI. None of the goodwill is expected to be deductible for income tax purposes. The purchase price includes an earn-out provision, which is dependent on achieving certain revenue and operational targets in the year following the acquisition. Based on projections at the time of acquisition, the earn-out was valued at $4.8 million. However, because the contractual obligation is binary, the actual payment will be either $10 million or $0. Adjustments to the earn-out based on information obtained subsequent to the acquisition are recorded through the income statement. As of December 31, 2020, the Company updated the earn-out value to $9.5 million, with the change being recorded as a component of other expenses. Included in the Consolidated Statements of Operations and Comprehensive Income (Loss) for the year ended December 31, 2020 are net sales of $20.7 million and net loss before income taxes of $6.9 million related to the operations of SCI since the acquisition date of April 1, 2020. RevWorks On August 3, 2020, the Company completed the acquisition of RevWorks. The RevWorks Acquisition has been accounted for under ASC 805, Business Combinations. Accordingly, the accounts of the acquired company, after adjustments to reflect estimated fair values assigned to assets and liabilities, have been included in the Company’s consolidated financial statements since the date of the RevWorks Acquisition. The $30.0 million purchase consideration for the RevWorks Acquisition (inclusive of working capital) consisted of a $5.0 million payment at closing and two deferred payments, each of $12.5 million and totaling $25.0 million, which are due and payable on the first and second anniversary of the closing date. The two deferred payments are contractual obligations of the Company; however, they are potentially effectively refundable to the Company contingent on the achievement of certain pre-existing customer revenue targets for the RevWorks business that were agreed in the purchase agreement. If such targets are not achieved, this will result in Cerner Corporation (“Cerner”) returning to the Company up to $25.0 million. At the time of the acquisition, the Company recorded a present value liability for the contractual deferred payments of $24.3 million, and recorded an asset for the contingently returnable consideration of $22.3 million, including $11.5 million in prepaid expenses and other current assets and $10.8 million in other assets on the Consolidated Balance Sheets, which is measured at fair value. The Company reviewed the balances at December 31, 2020 and determined the fair value remained the same. The assets acquired in the RevWorks Acquisition consist primarily of customer relationships of approximately $2.8 million and fixed assets. There were no significant pre-closing liabilities of the RevWorks business included in the RevWorks Acquisition. The fair value estimate of assets acquired and liabilities assumed are pending completion of multiple elements, including gathering further information about the identification and completeness of all assets and liabilities acquired. The goodwill recognized of approximately $3.6 million is primarily attributable to synergies that are expected to be achieved from the integration of RevWorks. Included in the Consolidated Statements of Operations and Comprehensive Income (Loss) for the year ended December 31, 2020 are net sales of $26.8 million and net income before income taxes of $0.5 million related to the operations of RevWorks since the acquisition date of August 3, 2020. Pro Forma Results (Unaudited) The following table summarizes, on a pro forma basis, the combined results of the Company as though the SCI and RevWorks acquisitions had occurred as of January 1, 2019. These pro forma results are not necessarily indicative of either the actual consolidated results had the acquisitions occurred as of January 1, 2019 or of the future consolidated operating results. Pro forma results are (in millions): Year Ended December 31, 2020 2019 Net services revenue $ 1,320.9 $ 1,297.7 Net income (loss) $ 115.7 $ (1.6) Supplemental pro-forma earnings were adjusted to exclude $6.0 million of acquisition-related costs incurred by the Company in 2020 and include those costs in 2019. Adjustments were also made to earnings to adjust depreciation and amortization to reflect fair value of identified assets acquired, to record the effects of extinguishing the debt of SCI and replacing it with the debt of the Company, and to record the income tax effect of these adjustments.

Accounts Receivable and Allowan

Accounts Receivable and Allowance for Credit Losses	12 Months Ended
	Dec. 31, 2020
Receivables [Abstract]
Accounts Receivable and Allowance for Credit Losses	Accounts Receivable and Allowance for Credit LossesAccounts receivable is comprised of unpaid balances pertaining to modular services and end-to-end RCM services, net receivable balances for end-to-end RCM services after considering cost reimbursements owed to customers, including related accrued balances, and amounts due from physician RCM and PM customers. On January 1, 2020 (the “adoption date”), the Company replaced its previous incurred loss impairment model for estimating credit losses on accounts receivables with an expected loss model prepared in accordance with ASC 326. While the incurred loss impairment model had the Company recognize credit losses when it was probable that a loss had been incurred, ASC 326 requires the Company to estimate future expected credit losses on such instruments before an impairment may occur. On the adoption date, the Company recorded an initial increase of $1.1 million to the Company's allowance for credit losses, with an offset recorded as an opening adjustment to accumulated deficit and deferred tax assets. The full effects of COVID-19 on the Company’s customers are uncertain and cannot be predicted. As a result, the Company’s future collection experience may differ from historical collection trends. The Company has presented the rollforward below on a consolidated basis as the currently expected credit losses for its large integrated healthcare system customers are not anticipated to be material. Movements in the allowance for credit losses are as follows (in millions): Year Ended December 31, 2020 2019 Beginning balance $ 2.8 $ 1.1 Cumulative effect of ASC 326 adoption 1.1 — Provision (recoveries) 0.6 3.1 EMS Disposition (0.6) — Write-offs (0.1) (1.4) Ending balance $ 3.8 $ 2.8

Property, Equipment and Softwar

Property, Equipment and Software	12 Months Ended
	Dec. 31, 2020
Property, Plant and Equipment [Abstract]
Property, Equipment and Software	Property, Equipment and Software Property, equipment and software consist of the following (in millions): December 31, 2020 December 31, 2019 Buildings and land $ 4.6 $ 4.6 Computer and other equipment 55.0 50.7 Leasehold improvements 23.2 31.1 Software 135.7 123.0 Office furniture 6.4 9.4 Property, equipment and software, gross 224.9 218.8 Less accumulated depreciation and amortization (131.2) (101.9) Property, equipment and software, net $ 93.7 $ 116.9 Property, equipment and software, net, located internationally was $17.1 million and $14.8 million as of December 31, 2020 and 2019, respectively. The remaining property, equipment and software was located in the U.S. The following table summarizes the allocation of depreciation and amortization expense between cost of services and selling, general and administrative expenses (in millions): Year Ended December 31, 2020 2019 2018 Cost of services $ 46.6 $ 37.8 $ 23.9 Selling, general and administrative 4.0 4.0 4.3 Total depreciation and amortization $ 50.6 $ 41.8 $ 28.2

Leases

Leases	12 Months Ended
	Dec. 31, 2020
Leases [Abstract]
Leases	Leases The Company determines if an arrangement is a lease at inception. Operating leases are included in operating lease ROU assets, current portion of operating lease liabilities, and non-current portion of operating lease liabilities on the consolidated balance sheets. Finance lease ROU assets are included in property, equipment and software, net, and the current and non-current portion of financing lease liabilities are included in other accrued expenses and other non-current liabilities, respectively, on the consolidated balance sheets. ROU assets represent the Company's right to control the use of the underlying assets for the lease term and lease liabilities represent the Company's obligations to make lease payments arising from the Company's portfolio of leases. Operating and finance lease ROU assets and liabilities are recognized at the lease commencement date based on the present value of lease payments over the lease term. As the Company's leases do not provide an implicit rate, the incremental borrowing rate, determined based on the information available at the lease commencement date, is used in calculating the present value of lease payments. ROU assets also include any lease prepayments made and excludes any lease incentives. The Company's leases may include options to extend the lease term and the Company's determination of the likely lease term incorporates these options when it is reasonably certain that they will be exercised. The Company elected to not separate lease and non-lease components for building and equipment leases. The Company will account for the lease and non-lease components, such as fixed service charges, as a single lease component. Leases with an initial term of 12 months or less are not recorded on the balance sheet; lease expense is recognized for these short-term leases on a straight-line basis over the lease term. The Company has operating and finance leases for corporate offices, operational facilities, global business services centers, and certain equipment. Leases have remaining lease terms of up to 13 years, some of which include options to extend the leases for up to 10 years. In circumstances where there are significant foreign tax incentives, the Company has determined it to be reasonably certain to exercise the renewal options. The Company subleases certain office spaces to third parties. The components of lease costs are as follows (in millions): Year Ended December 31, 2020 2019 Operating lease cost $ 18.2 $ 19.1 Finance lease cost: Amortization of ROU assets 0.4 0.8 Interest on lease liabilities 0.1 0.1 Sublease income (2.2) (2.2) Total lease cost $ 16.5 $ 17.8 Supplemental cash flow information related to leases are as follows (in millions): Year Ended December 31, 2020 2019 Cash paid for amounts included in the measurement of lease liabilities: Operating cash flows for operating leases $ 20.7 $ 18.7 Operating cash flows for finance leases 0.1 0.1 Financing cash flows for finance leases 0.8 0.8 ROU assets obtained in exchange for lease obligations: Operating leases 3.3 17.3 Finance leases — 0.7 The Company presents all non-cash transactions related to adjustments to the lease liability or ROU asset as non-cash transactions. This includes all non-cash charges related to any modification or reassessment events triggering remeasurement. Supplemental balance sheet information related to leases are as follows: December 31, 2020 December 31, 2019 Weighted average remaining lease term: Operating leases 7 years 8 years Finance leases 2 years 2 years Weighted average incremental borrowing rate: Operating leases 8.94 % 8.84 % Finance leases 6.62 % 6.45 % Maturities of lease liabilities as of December 31, 2020 are as follows (in millions): Operating Leases Finance Leases 2021 $ 18.7 $ 0.5 2022 16.1 0.1 2023 15.3 — 2024 15.0 — 2025 14.8 — Thereafter 34.0 — Total 113.9 0.6 Less: Imputed interest 30.7 — Present value of lease liabilities $ 83.2 $ 0.6
Leases	Leases The Company determines if an arrangement is a lease at inception. Operating leases are included in operating lease ROU assets, current portion of operating lease liabilities, and non-current portion of operating lease liabilities on the consolidated balance sheets. Finance lease ROU assets are included in property, equipment and software, net, and the current and non-current portion of financing lease liabilities are included in other accrued expenses and other non-current liabilities, respectively, on the consolidated balance sheets. ROU assets represent the Company's right to control the use of the underlying assets for the lease term and lease liabilities represent the Company's obligations to make lease payments arising from the Company's portfolio of leases. Operating and finance lease ROU assets and liabilities are recognized at the lease commencement date based on the present value of lease payments over the lease term. As the Company's leases do not provide an implicit rate, the incremental borrowing rate, determined based on the information available at the lease commencement date, is used in calculating the present value of lease payments. ROU assets also include any lease prepayments made and excludes any lease incentives. The Company's leases may include options to extend the lease term and the Company's determination of the likely lease term incorporates these options when it is reasonably certain that they will be exercised. The Company elected to not separate lease and non-lease components for building and equipment leases. The Company will account for the lease and non-lease components, such as fixed service charges, as a single lease component. Leases with an initial term of 12 months or less are not recorded on the balance sheet; lease expense is recognized for these short-term leases on a straight-line basis over the lease term. The Company has operating and finance leases for corporate offices, operational facilities, global business services centers, and certain equipment. Leases have remaining lease terms of up to 13 years, some of which include options to extend the leases for up to 10 years. In circumstances where there are significant foreign tax incentives, the Company has determined it to be reasonably certain to exercise the renewal options. The Company subleases certain office spaces to third parties. The components of lease costs are as follows (in millions): Year Ended December 31, 2020 2019 Operating lease cost $ 18.2 $ 19.1 Finance lease cost: Amortization of ROU assets 0.4 0.8 Interest on lease liabilities 0.1 0.1 Sublease income (2.2) (2.2) Total lease cost $ 16.5 $ 17.8 Supplemental cash flow information related to leases are as follows (in millions): Year Ended December 31, 2020 2019 Cash paid for amounts included in the measurement of lease liabilities: Operating cash flows for operating leases $ 20.7 $ 18.7 Operating cash flows for finance leases 0.1 0.1 Financing cash flows for finance leases 0.8 0.8 ROU assets obtained in exchange for lease obligations: Operating leases 3.3 17.3 Finance leases — 0.7 The Company presents all non-cash transactions related to adjustments to the lease liability or ROU asset as non-cash transactions. This includes all non-cash charges related to any modification or reassessment events triggering remeasurement. Supplemental balance sheet information related to leases are as follows: December 31, 2020 December 31, 2019 Weighted average remaining lease term: Operating leases 7 years 8 years Finance leases 2 years 2 years Weighted average incremental borrowing rate: Operating leases 8.94 % 8.84 % Finance leases 6.62 % 6.45 % Maturities of lease liabilities as of December 31, 2020 are as follows (in millions): Operating Leases Finance Leases 2021 $ 18.7 $ 0.5 2022 16.1 0.1 2023 15.3 — 2024 15.0 — 2025 14.8 — Thereafter 34.0 — Total 113.9 0.6 Less: Imputed interest 30.7 — Present value of lease liabilities $ 83.2 $ 0.6

Intangible Assets

Intangible Assets	12 Months Ended
	Dec. 31, 2020
Goodwill and Intangible Assets Disclosure [Abstract]
Intangible Assets	Intangible AssetsThe following table provides the gross carrying value and accumulated amortization for each major class of intangible asset at December 31, 2020 and December 31, 2019 (in millions): December 31, 2020 December 31, 2019 Gross Carrying Value Accumulated Amortization Net Book Value Gross Carrying Value Accumulated Amortization Net Book Value Customer relationships $ 97.7 $ (14.7) $ 83.0 $ 160.9 $ (15.6) $ 145.3 Technology 101.7 (13.6) 88.1 26.8 (7.4) 19.4 Total intangible assets $ 199.4 $ (28.3) $ 171.1 $ 187.7 $ (23.0) $ 164.7 The Company acquired the following intangible assets in 2020 (in millions, except weighted average useful life): Weighted Average Useful Life Gross Carrying Value Customer relationships 10 years $ 5.6 Technology 10 years $ 85.3 The fair value of the identifiable intangible assets was derived utilizing an income approach to derive the present value of future cash flows from developed technology and customer relationships. Intangible asset amortization expense was $18.1 million and $13.9 million for the year ended December 31, 2020 and 2019, respectively. Estimated annual amortization expense related to intangible assets with definite lives as of December 31, 2020 is as follows (in millions): 2021 $ 17.3 2022 17.3 2023 17.3 2024 15.5 2025 14.5 Thereafter 89.2 Total $ 171.1

Goodwill

Goodwill	12 Months Ended
	Dec. 31, 2020
Goodwill and Intangible Assets Disclosure [Abstract]
Goodwill	Goodwill Changes in the carrying amount of goodwill for the year ended December 31, 2020 were (in millions): Goodwill Balance as of December 31, 2019 $ 253.2 Acquisitions 129.2 EMS Disposition (7.1) Balance as of December 31, 2020 $ 375.3 There was no impairment of goodwill in 2020 and 2019.

Revenue Recognition

Revenue Recognition	12 Months Ended
	Dec. 31, 2020
Revenue from Contract with Customer [Abstract]
Revenue Recognition	Revenue Recognition Disaggregation of Revenue In the following table, revenue is disaggregated by source of revenue (in millions): Year Ended December 31, 2020 2019 2018 Net operating fees $ 1,093.8 $ 1,037.4 $ 760.2 Incentive fees 70.6 56.2 38.3 Other 106.4 92.5 70.0 Net services revenue $ 1,270.8 $ 1,186.1 $ 868.5 Contract Balances The following table provides information about receivables, contracts assets, and contract liabilities from contracts with customers (in millions): December 31, 2020 December 31, 2019 Receivables (1) $ 122.2 $ 83.1 Contract assets (2) — 2.0 Contract liabilities (2) 28.6 25.3 (1) Receivables are included in accounts receivable, net. The balance includes accounts receivable, net - related party. (2) Contract assets and contract liabilities are included in other current assets and customer liabilities, respectively. The contract liabilities balance contains related party amounts, including $5.6 million and $4.2 million of current customer liabilities and $16.3 million and $18.6 million of non-current customer liabilities for the year ended December 31, 2020 and 2019, respectively. A receivable is recognized in the period the Company provides services when the Company’s right to consideration is unconditional. Payment terms on invoiced amounts are typically 30-60 days. The Company recognized revenue of $91.6 million and $69.7 million during the year ended December 31, 2020 and 2019, which amounts were included in contract liabilities at the beginning of the respective periods. These revenue amounts include $85.0 million and $66.7 million for the year ended December 31, 2020 and 2019, respectively, related to advanced billings which become accounts receivable and contract liabilities on the first day of the respective service period. Transaction Price Allocated to the Remaining Performance Obligation The following table includes estimated revenue expected to be recognized in the future related to performance obligations that are unsatisfied (or partially unsatisfied) at the end of the reporting period (in millions). The estimated revenue does not include amounts of variable consideration that are constrained. Net operating fees Incentive fees Other 2021 $ 112.6 $ 4.1 $ 3.7 2022 62.3 17.6 5.7 2023 48.0 — 5.7 2024 27.5 — 5.7 2025 18.3 — 2.9 Thereafter 12.7 — — Total $ 281.4 $ 21.7 $ 23.7 The amounts presented in the table above include variable fee estimates for the non-cancellable term of the Company's physician groups RCM services contracts, fixed fees which are typically recognized ratably as the performance obligation is satisfied, and incentive fees which are measured cumulatively over the contractually defined performance period. Estimates of revenue expected to be recognized in future periods also exclude unexercised customer options to purchase services within the Company's PAS contracts that do not represent material rights to the customer. Customer options that do not represent a material right are only accounted for in accordance with Topic 606 when the customer exercises its option to purchase additional goods or services. The Company does not disclose information about remaining performance obligations with an original expected duration of one year or less. The Company has elected certain of the optional exemptions from the disclosure requirement for remaining performance obligations for specific situations in which an entity need not estimate variable consideration to recognize revenue. Accordingly, the Company applies a practical expedient to its modular RCM services and does not disclose information about variable consideration from remaining performance obligations when the Company has a right to consideration from a customer in an amount that corresponds directly with the value to the customer of the entity's performance completed to date. PAS performance obligations are typically short in duration (often less than 1 day) with any uncertainty related to the associated variable consideration resolved as each increment of service (completion of a level of care review or an appeal) is completed which reflects the value the customer receives from the Company’s fulfillment of the performance obligation. Modular RCM services performance obligations for variable consideration are of short duration with fees corresponding to the value the customer has realized, for example, patient accounts collected on behalf of the customer or medical record lines transcribed. For end-to-end RCM contracts, the Company does not disclose information about remaining, wholly unsatisfied performance obligations for variable consideration that the Company is able to allocate to one or more, but not all, of the performance obligations in its contracts. The Company’s end-to-end RCM services performance obligations are satisfied over time and are substantially the same from period to period under either a co-managed or operating partner model. Fees are variable and consist of net operating fees and incentive fees, with the uncertainty related to net operating fees and certain incentive fees being resolved quarterly, and with the uncertainty of other incentive fees being resolved annually. The information presented in the table above includes estimates for incentive fees where the uncertainty related to the final fee is resolved on longer than a quarterly basis and to the extent the Company does not believe the associated consideration is constrained. December 31, 2020 December 31, 2019 Prepaid expenses and other current assets $ 4.5 $ 4.0 Other assets 19.6 20.8 Total deferred contract costs $ 24.1 $ 24.8

Customer Liabilities

Customer Liabilities	12 Months Ended
	Dec. 31, 2020
Other Liabilities Disclosure [Abstract]
Customer Liabilities	Customer LiabilitiesCustomer liabilities include (i) accrued service costs (amounts due and accrued for cost reimbursements), (ii) collections payable to clients (consisting primarily of amounts collected on behalf of the Company’s physician group customers to be remitted within twelve months), (iii) refund liabilities (amounts potentially due as a refund to the Company's customers on incentive fees), (iv) customer deposits (consisting of amounts due as a refund to the Company's customers on incentive fees) and (v) deferred revenue (contract liabilities) (fixed or variable fees amortized to revenue over the service period). Customer liabilities consist of the following (in millions): December 31, 2020 December 31, 2019 Accrued service costs, current $ 12.2 $ 33.3 Collections payable to clients, current 4.6 5.4 Customer deposits, current — 1.7 Refund liabilities, current 2.9 1.0 Deferred revenue (contract liabilities), current 12.3 6.7 Current portion of customer liabilities (1) 32.0 48.1 Deferred revenue (contract liabilities), non-current 16.3 18.6 Non-current portion of customer liabilities (1) 16.3 18.6 Total customer liabilities $ 48.3 $ 66.7 (1) Current and non-current portion of customer liabilities include amounts for a related party. See Note 21, Related Party Transactions, for further discussion.

Debt

Debt	12 Months Ended
	Dec. 31, 2020
Debt Disclosure [Abstract]
Debt	Debt The carrying amounts of debt consist of the following (in millions): December 31, 2020 December 31, 2019 Senior Revolver $ 70.0 $ 40.0 Senior Term Loan 484.6 316.9 Unamortized discount and issuance costs (2.6) (2.9) Total debt 552.0 354.0 Less: Current maturities (32.3) (16.3) Total long-term debt $ 519.7 $ 337.7 Senior Secured Credit Facilities On June 26, 2019, the Company and certain of its subsidiaries entered into a new senior credit agreement (the “Credit Agreement”) with Bank of America, N.A., as administrative agent, and the lenders named therein, for the new senior secured credit facilities (the “Senior Secured Credit Facilities”), consisting of a $325.0 million senior secured term loan facility (the “Senior Term Loan”) issued at 99.66% of par and a $100.0 million senior secured revolving credit facility (the “Senior Revolver”). In conjunction with entering into the Credit Agreement, the Company repaid in full the credit agreement dated May 8, 2018, the subordinated notes issued under the Subordinated Note Purchase Agreement dated May 8, 2018, and terminated all commitments and discharged all guarantees related to those agreements. The Company evaluated separately the previous credit agreement, subordinated notes, and revolver for debt modification and extinguishment guidance as indicated in ASC 470. The Company deemed the refinancing to be an extinguishment of the old debt, leading to a write-off of the prior issuance costs and recognition of new issuance costs, with the exception of a portion of the revolver which remained with the same lender. The Company recognized a loss on debt extinguishment of $18.8 million in the second quarter of 2019. On March 20, 2020, the Company entered into Amendment No. 1 to the Credit Agreement (the “Amendment”), pursuant to which the lenders named in the Amendment agreed to provide an additional $191.1 million incremental delayed-draw term loan facility (the “Incremental Term Loan”) on the same terms as its existing Senior Term Loan provided under the Credit Agreement. The Incremental Term Loan was drawn substantially concurrently with the closing of the SCI Acquisition on April 1, 2020. The proceeds of the Incremental Term Loan were used to fund the purchase price for the SCI Acquisition and related expenses. For further details on the closing, refer to Note 5, Acquisitions. The Incremental Term Loan has terms consistent with those of the Senior Term Loan, including with respect to interest, maturity, amortization, and prepayments and has the same affirmative and negative covenants and events of default as those applicable to the Senior Term Loan under the Credit Agreement. The drawing of the Incremental Term Loan increased the balance of the obligation due under the Senior Term Loan, and therefore is shown as one consolidated obligation. In accordance with ASC 470-50, the Amendment was treated as a loan modification in the financial statements. On January 13, 2021, the Company entered into Amendment No. 2 and Waiver to Credit Agreement (the “Second Amendment”), pursuant to which the lenders agreed (i) to waive the Company’s obligation to use the $135.0 million of net proceeds from the EMS Disposition for purposes of reinvestments in useful assets of the Company, or to prepay the loans under the Credit Agreement, as otherwise required by the terms of the Credit Agreement, (ii) to amend the restricted payments covenant to permit the Company to make additional cash payments to the Investor in an amount not to exceed $105.0 million in connection with the preferred stock conversion (refer to Note 18. 8.00% Series A Convertible Preferred Stock) and reduce the “Available Amount” from which the Company can make certain investments, debt prepayments, or restricted payments by $105.0 million and (iii) that the excess cash flow sweep will begin with fiscal year ended December 31, 2021 instead of fiscal year ended December 31, 2020. The Senior Term Loan and Senior Revolver both have a five-year maturity. The Credit Agreement provides that the Company may make one or more offers to the lenders, and consummate transactions with individual lenders that accept the terms contained in such offers, to extend the maturity date of the lender’s term loans and/or revolving commitments, subject to certain conditions, and any extended term loans or revolving commitments will constitute a separate class of term loans or revolving commitments. All of the Company’s obligations under the Senior Secured Credit Facilities are guaranteed by the subsidiary guarantors named therein (the “Subsidiary Guarantors”). Pursuant to (1) the Security Agreement, dated as of June 26, 2019 (the “Security Agreement”), among the Company, the Subsidiary Guarantors and Bank of America, N.A., as administrative agent, and (2) the Guaranty, dated as of June 26, 2019 (the “Guaranty”), among the Company, the Subsidiary Guarantors and Bank of America, N.A., as administrative agent, subject to certain exceptions, the obligations under the Senior Secured Credit Facilities are secured by a pledge of 100% of the capital stock of certain domestic subsidiaries owned by the Company and a security interest in substantially all of the Company’s tangible and intangible assets and the tangible and intangible assets of each Subsidiary Guarantor. The Senior Revolver includes borrowing capacity available for letters of credit and for borrowings on same-day notice, referred to as the “swing loans.” Any issuance of letters of credit or making of a swing loan will reduce the amount available under the revolving credit facility. As of December 31, 2020, the Company had $70.0 million in borrowings, no letters of credit outstanding, and $30.0 million of availability under the Senior Revolver. Borrowings under the Senior Secured Credit Facilities bear interest, at the Company’s option, at: (i) an Alternate Base Rate (“ABR”) equal to the greater of (a) the prime rate of Bank of America, N.A., (b) the federal funds rate plus 0.50% per annum , and (c) the Eurodollar rate for an interest period of one-month beginning on such day plus 100 basis points, plus between 0.75% and 1.75% dependent on the Company's Net Leverage Ratio (as defined below) (provided that the Eurodollar rate applicable to the Senior Term Loan shall not be less than 0.00% per annum); or (ii) the Eurodollar rate (provided that the Eurodollar rate applicable to the Senior Term Loan shall not be less than 0.00% per annum), plus between 1.75% and 2.75%, dependent on the Company's Net Leverage Ratio. The interest rate as of December 31, 2020 was 2.40%. The Company is also required to pay an unused commitment fee to the lenders under the Senior Revolver at a rate between 0.30% and 0.50% of the average daily unutilized commitments thereunder dependent on the Company's net leverage ratio. The Credit Agreement requires the Company to make mandatory prepayments, subject to certain exceptions, with: (i) beginning with fiscal year ended December 31, 2021, 50% (which percentage will be reduced upon the Company’s achievement of certain total net leverage ratios) of the Company’s annual excess cash flow; (ii) 100% of net cash proceeds of all non-ordinary course assets sales or other dispositions of property or casualty events, subject to certain exceptions and thresholds; and (iii) 100% of the net cash proceeds of any debt incurrence, other than debt permitted under the Credit Agreement. The Company is required to repay the Senior Term Loan portion of the Senior Secured Credit Facilities in quarterly principal installments of $6.5 million through June 30, 2021, $9.7 million through June 30, 2023, and $12.9 million through March 31, 2024, with the balance payable at maturity. The Credit Agreement contains a number of covenants that, among other things, restrict, subject to certain exceptions, the Company’s ability and the ability of its subsidiaries to: (i) incur additional indebtedness; (ii) create liens on assets; (iii) engage in mergers or consolidations; (iv) sell assets; (v) pay dividends and distributions or repurchase the Company’s capital stock; (vi) make investments, loans or advances; (vii) repay certain junior indebtedness; (viii) engage in certain transactions with affiliates; (ix) enter into sale and leaseback transactions; (x) amend material agreements governing certain of the Company’s junior indebtedness; (xi) change the Company’s lines of business; (xii) make certain acquisitions; and (xiii) limitations on the letter of credit cash collateral account. The Credit Agreement contains customary affirmative covenants and events of default. In addition, the Company is required to maintain minimum consolidated total net leverage and consolidated interest coverage ratios. The Company was in compliance with all of the covenants in the Credit Agreement as of December 31, 2020. Debt Maturities Scheduled maturities of the Company's long-term debt for each of the five years succeeding December 31, 2020 and thereafter are summarized as follows (in millions): Scheduled Maturities 2021 $ 32.3 2022 38.7 2023 45.2 2024 438.4 Total $ 554.6

Stockholders' Equity (Deficit)

Stockholders' Equity (Deficit)	12 Months Ended
	Dec. 31, 2020
Equity [Abstract]
Stockholders' Equity (Deficit)	Stockholders’ Equity (Deficit) Preferred Stock and Warrants As of December 31, 2020 and December 31, 2019, the Company had 5,000,000 shares of authorized preferred stock, each with a par value of $0.01. The preferred stock may be issued from time to time in one or more series. The board of directors of the Company (“Board”) is authorized to determine the rights, preferences, privileges, and restrictions of the Company’s authorized but unissued shares of preferred stock. On February 16, 2016, at the close of the Transaction, the Company issued to TCP-ASC ACHI Series LLLP, a limited liability limited partnership jointly owned by Ascension Health Alliance and investment funds affiliated with TowerBrook (the “Investor”): (i) 200,000 shares of its 8.00% Series A Convertible Preferred Stock, par value $0.01 per share (the “Series A Preferred Stock” or “Preferred Stock”), for an aggregate price of $200 million and (ii) an exercisable warrant to acquire up to 60 million shares of its common stock with an exercise price of $3.50 per common share and a term of ten years. The Series A Preferred Stock is immediately convertible into shares of common stock. As of December 31, 2020 and December 31, 2019, the Company had 288,497 and 266,529 shares of Series A Preferred Stock outstanding, respectively. The Series A Preferred Stock was converted to common stock on January 15, 2021. See Note 18, 8.00% Series A Convertible Preferred Stock, for additional information. On January 23, 2018, the Company issued an exercisable warrant to acquire up to 1.5 million shares of its common stock with an exercise price of $6.00 per common share to IHC Health Services, Inc (“Intermountain”). As of December 31, 2020 and December 31, 2019, all of the Investor’s and Intermountain’s warrants were outstanding. Common Stock Each outstanding share of the Company's common stock, par value $0.01 per share (“common stock”), is entitled to one vote per share on all matters submitted to a vote by shareholders. Subject to the rights of any preferred stock which may from time to time be outstanding, the holders of outstanding shares of common stock are entitled to receive dividends and, upon liquidation or dissolution, are entitled to receive pro rata all assets legally available for distribution to stockholders. No dividends were declared or paid on the common stock during 2020 or 2019. Treasury Stock On November 13, 2013, the Board authorized a repurchase of up to $50.0 million of the Company’s common stock in the open market or in privately negotiated transactions. The timing and amount of any shares repurchased will be determined by the Company based on its evaluation of market conditions and other factors. The repurchase program may be suspended or discontinued at any time at the sole discretion of the Board. Any repurchased shares will be available for use in connection with the Company’s stock plans and for other corporate purposes. The Company funds the repurchases from cash on hand. During the years ended December 31, 2020 and December 31, 2019, no shares were repurchased. No shares have been retired. As of December 31, 2020 and 2019, the Company held in treasury 5,321,393 shares of repurchased stock. Treasury stock also includes repurchases of Company stock related to employees’ tax withholding upon vesting of restricted shares. For the years ended December 31, 2020 and 2019, the Company repurchased 2,882,255 and 973,303 shares related to employees’ tax withholding upon vesting of restricted shares, respectively. See Note 15, Share-Based Compensation, for additional information.

Share-Based Compensation

Share-Based Compensation	12 Months Ended
	Dec. 31, 2020
Share-based Payment Arrangement [Abstract]
Share-Based Compensation	Share-Based Compensation The Company maintains two stock incentive plans: the Amended and Restated Stock Option Plan (the “2006 Plan”) and the Second Amended and Restated Stock 2010 Incentive Plan (the “2010 Amended Plan”, together with the 2006 Plan, the “Plans”). In December 2016, the Company's stockholders approved the Second Amended and Restated 2010 Stock Incentive Plan, which authorized the issuance of an additional 17 million shares of the Company's common stock pursuant to awards. Under the Plans, the Company is authorized to issue up to a maximum of 46,374,756 shares of common stock. This number includes any shares that remained available for issuance under the 2006 Plan as of the date of the IPO and any shares subject to awards that were outstanding under the 2006 Plan as of the date of the IPO that expire, terminate or are otherwise surrendered, canceled, forfeited or repurchased by the Company without the issuance of shares thereunder. The Company will not make any further grants under the 2006 Plan. The 2010 Amended Plan provides for the grant of incentive stock options, non-statutory stock options, stock appreciation rights, RSAs, RSUs, and other share-based awards. As of December 31, 2020, 5,028,242 shares were available for future grants of awards under the 2010 Amended Plan. To the extent that previously granted awards under the 2006 Plan or 2010 Amended Plan expire, terminate or are otherwise surrendered, canceled or forfeited, the number of shares available for future awards under the 2010 Amended Plan will increase. Under the terms of the Plans, all stock options will expire if they are not exercised within ten years of their grant date. Generally all employee options, RSAs and RSUs vest ratably between one For the years ended December 31, 2020, 2019, and 2018, the Company recognized $37.3 million, $8.2 million, and $2.4 million, respectively, of income tax benefit from windfalls associated with vesting and exercises of equity awards The Company uses the Black-Scholes option pricing model to estimate the fair value of its service-based options as of its grant date. The Company uses the Monte Carlo simulations to estimate the fair value of its market-based PBRSUs. The market-based PBRSUs vest upon satisfaction of both time-based requirements and market targets based on share price. Expected life is based on the market condition to which the vesting is tied. The Company assesses current performance on performance-based PBRSU’s by reviewing historical performance to date, along with any adjustments which have been approved to the reported performance, and add on future projections to determine the probable outcome of the awards. The current estimates are then compared to the scoring metrics and any necessary adjustments are reflected in the current period to update share-based compensation expense to the current performance expectations. The following table sets forth the significant assumptions used in the Black-Scholes option pricing model and the Monte Carlo simulations and the calculation of share-based compensation expense during 2020, 2019, and 2018: Year Ended December 31, 2020 2019 2018 Expected dividend yield —% —% —% Risk-free interest rate 0.3% to 1.7% 1.5% to 2.5% 2.3% to 3.0% Expected volatility 43% 40% to 45% 40% to 45% Expected term (in years) 5.5 2.0 to 5.5 2.6 to 6.3 Total share-based compensation costs that have been included in the Company’s consolidated statements of operations were as follows (in millions): Year Ended December 31, 2020 2019 2018 Share-Based Compensation Expense Allocation Details: Cost of services $ 9.9 $ 6.1 $ 5.8 Selling, general and administrative 14.1 12.3 12.4 Other 0.1 0.2 0.2 Total share-based compensation expense (1) $ 24.1 $ 18.6 $ 18.4 (1) In addition to the share-based compensation expense recorded above, $0.1 million , $0.2 million, and $0.3 million of share-based compensation expense was capitalized to deferred contract costs for the year ended December 31, 2020 , 2019, and 2018, respectively. See Note 22, Deferred Contract Costs, for further discussion. Stock options The following table sets forth a summary of all option activity under all plans for the years ended December 31, 2020, 2019, and 2018: Shares Weighted- Weighted- Aggregate Outstanding at January 1, 2018 17,742,966 $ 4.70 7.9 $ 23.7 Granted 274,162 6.51 Exercised (1,713,710) 2.54 Canceled/forfeited (2,418,948) 2.60 Outstanding at December 31, 2018 13,884,470 $ 5.36 6.6 $ 49.2 Granted 52,986 10.06 Exercised (2,640,897) 5.20 Canceled/forfeited (612,299) 2.55 Expired (3,920) 12.98 Outstanding at December 31, 2019 10,680,340 $ 5.59 5.5 $ 81.1 Granted 80,425 11.18 Exercised (3,156,154) 6.13 Canceled/forfeited (169,420) 3.32 Expired (1,214,220) 14.62 Outstanding at December 31, 2020 6,220,971 $ 3.68 5.7 $ 126.5 Outstanding, vested and exercisable at December 31, 2018 7,712,264 $ 7.37 5.4 $ 17.7 Outstanding, vested and exercisable at December 31, 2019 7,868,280 $ 6.57 4.9 $ 52.5 Outstanding, vested and exercisable at December 31, 2020 5,230,690 $ 3.73 5.5 $ 106.2 The weighted-average grant date fair value of options granted during the years ended December 31, 2020, 2019, and 2018 was $4.41, $4.25, and $3.01 per share, respectively. The total intrinsic value of the options exercised in the years ended December 31, 2020, 2019, and 2018 was $30.5 million, $16.4 million, and $9.6 million, respectively. The total fair value of options vested during the years ended December 31, 2020, 2019, and 2018 was $2.2 million, $3.4 million, and $4.2 million, respectively. Restricted stock awards As of December 31, 2019, all RSAs had fully vested. No new RSAs were granted in 2020. The following table sets forth a summary of the activity during the years ended December 31, 2019 and 2018: Shares Weighted- Outstanding and unvested at January 1, 2018 2,352,490 $ 3.03 Vested (1,184,687) 3.07 Forfeited (72,259) 3.24 Outstanding and unvested at December 31, 2018 1,095,544 $ 3.02 Vested (1,094,336) 3.02 Forfeited (1,208) 5.38 Outstanding and unvested at December 31, 2019 — $ — The total fair value of RSAs vested during the years ended December 31, 2019, and 2018 was $3.3 million and $3.6 million, respectively. The Company’s RSA agreements allowed employees to deliver to the Company shares of stock upon vesting of their RSAs in lieu of their payment of the required personal employment-related taxes. The Company does not withhold taxes in excess of maximum required statutory requirements. During the years ended December 31, 2019, and 2018, employees delivered to the Company 380,564 and 404,466 shares of stock, respectively, which the Company recorded at a cost of approximately $3.8 million and $2.3 million, respectively. Forfeited and canceled RSAs are added to treasury stock. For the years ended December 31, 2019, and 2018, 1,208, and 72,259 shares were added to treasury stock due to canceled RSAs, respectively. Restricted stock units The following table sets forth a summary of all RSU activity during the years ended December 31, 2020, 2019, and 2018: Shares Weighted- Outstanding and unvested at January 1, 2018 1,183,500 $ 2.50 Granted 441,849 7.99 Vested (323,964) 2.48 Forfeited (174,704) 3.49 Outstanding and unvested at December 31, 2018 1,126,681 $ 4.50 Granted 830,668 10.60 Vested (422,770) 4.07 Forfeited (161,223) 7.00 Outstanding and unvested at December 31, 2019 1,373,356 $ 8.03 Granted 1,588,120 10.29 Vested (504,708) 6.74 Forfeited (348,321) 9.09 Outstanding and unvested at December 31, 2020 2,108,447 $ 9.87 The Company's RSU agreements allow employees to surrender to the Company shares of common stock upon vesting of their RSUs in lieu of their payment of the required personal employment-related taxes. During the years ended December 31, 2020, 2019, and 2018, employees delivered to the Company 141,331, 109,112, and 94,603 shares of stock, respectively, which the Company recorded at a cost of approximately $1.4 million, $1.1 million, and $0.7 million, respectively. Shares surrendered for payment of personal employment-related taxes are held in treasury. Performance-based restricted stock units Outstanding PBRSUs issued prior to April 2019 vest upon satisfaction of both time-based requirements and market targets based on share price with certain awards vesting between December 31, 2021 and December 31, 2022. Depending on the percentage level at which the market-based condition is satisfied, the number of shares vesting could be between 0% and 150% of the number of PBRSUs originally granted. PBRSUs issued subsequent to April 2019 vest either in December 2021 or December 2022 upon satisfaction of both time-based and performance-based conditions. Depending on the award, performance condition targets may include cumulative adjusted EBITDA, end-to-end RCM agreement growth, scored revenue growth, or other specific performance factors. Depending on the percentage level at which the performance-based conditions are satisfied, the number of shares vesting could be between 0% and 200% of the number of PBRSUs originally granted. Based on the established targets, the maximum number of shares that could vest for all outstanding PBRSUs is 5,363,408. A summary of the PBRSU activity during the years ended December 31, 2020, 2019, and 2018 is shown below: Shares Weighted- Outstanding and unvested at January 1, 2018 4,785,900 $ 3.37 Granted 1,472,677 6.12 Vested — — Forfeited (1,648,129) 3.34 Outstanding and unvested at December 31, 2018 4,610,448 $ 4.26 Granted 1,282,797 9.99 Performance factor adjustment 463,408 2.06 Vested (1,390,223) 2.06 Forfeited (846,994) 5.08 Outstanding and unvested at December 31, 2019 4,119,436 $ 6.37 Granted 1,637,581 13.25 Performance factor adjustment 3,879,186 14.72 Vested (6,344,151) 13.11 Forfeited (374,981) 6.66 Outstanding and unvested at December 31, 2020 2,917,071 $ 11.35 The Company’s PBRSU agreements allow employees to surrender to the Company shares of common stock upon vesting of their PBRSUs in lieu of their payment of the required personal employment-related taxes. During the years ended December 31, 2020 and 2019, employees delivered to the Company 2,740,924 and 483,627 shares of stock, respectively, which the Company recorded at a cost of approximately $64.2 million and $6.1 million, respectively. Shares surrendered for payment of personal employment-related taxes are held in treasury.

Other expenses

Other expenses	12 Months Ended
	Dec. 31, 2020
Other Income and Expenses [Abstract]
Other expenses	Other expenses For the year ended December 31, 2020, 2019, and 2018, other expenses consist of the following (in millions): Year Ended December 31, 2020 2019 2018 Severance and related employee benefits $ 6.4 $ 3.6 $ 2.3 Strategic initiatives (1) 29.3 19.8 19.7 Transitioned employees restructuring expense (2) (0.2) 3.0 4.3 Digital Transformation Office (3) — 8.6 3.6 Facility-exit charges (4) 17.5 (0.2) 0.1 Other (5) 14.3 1.4 0.4 Total other expenses $ 67.3 $ 36.2 $ 30.4 (1) Costs related to evaluating, pursuing, and integrating acquisitions, performing portfolio and capital structure analyses, and other inorganic business projects as part of the Company’s growth strategy. Costs include vendor spend, employee time and expenses spent on activities, severance and retention amounts associated with integration activities, and changes to contingent consideration related to acquisitions. For the year ended December 31, 2020, $4.7 million of contingent consideration changes were included. (2) As part of the transition of personnel to the Company under certain operating partner model contracts, the Company has agreed to reimburse, or directly pay the affected employees, for certain severance and retention costs related to certain employees who will not be transitioned to the Company, or whose jobs will be relocated after the employee transitions to the Company. (3) Project costs related to the Company's initial efforts to automate its transactional environment. (4) As part of evaluating our footprint, we have exited certain leased facilities during the year ended December 31, 2020. Costs include asset impairment charges and other costs related to exited leased facilities. (5) For the year ended December 31, 2020, includes $10.9 million of expenses related to the COVID-19 pandemic, inclusive of appreciation bonuses for the Company’s front-line employees, pandemic response mobilization efforts, telemedicine and testing costs for employees, and other costs.

Income Taxes

Income Taxes	12 Months Ended
	Dec. 31, 2020
Income Tax Disclosure [Abstract]
Income Taxes	Income Taxes The domestic and foreign components of income (loss) before income taxes consist of the following (in millions): Year Ended December 31, 2020 2019 2018 Domestic $ 99.4 $ 5.0 $ (65.5) Foreign 19.0 4.8 8.8 Total income (loss) before income taxes $ 118.4 $ 9.8 $ (56.7) For the years ended December 31, 2020, 2019, and 2018, the Company’s current and deferred income tax expense (benefit) attributable to income (loss) from operations are as follows (in millions): Current Deferred Total Year Ended December 31, 2018 U.S. Federal $ — $ (10.3) $ (10.3) State & Local 0.9 (2.6) (1.7) Foreign 1.9 (1.3) 0.6 $ 2.8 $ (14.2) $ (11.4) Year Ended December 31, 2019 U.S. Federal $ (0.3) $ (2.2) $ (2.5) State & Local 0.7 (0.9) (0.2) Foreign 2.5 (2.0) 0.5 $ 2.9 $ (5.1) $ (2.2) Year Ended December 31, 2020 U.S. Federal $ 0.2 $ (0.3) $ (0.1) State & Local — 1.0 1.0 Foreign 2.4 (2.0) 0.4 $ 2.6 $ (1.3) $ 1.3 Reconciliation of the difference between the effective tax rate and the statutory U.S. federal income tax rate is as follows: Year Ended December 31, 2020 2019 2018 Federal statutory tax rate 21 % 21 % 21 % Increase in income tax rate resulting from: State and local income taxes, net of federal tax benefits 1 % (2) % 2 % Additional tax on foreign source income 3 % 18 % (3) % Share-based compensation (24) % (71) % 3 % Non-deductible expense 13 % 24 % (3) % Gain on sale (11) % — % — % Other (2) % (12) % — % Effective tax rate 1 % (22) % 20 % The following table sets forth the Company’s net deferred tax assets as of December 31, 2020 and 2019 (in millions): As of December 31, 2020 2019 Deferred tax assets and liabilities: Net operating loss carryforwards $ 81.6 $ 64.1 Share-based compensation 8.6 12.4 Accrued bonus 1.4 8.3 Advanced billing revenue 6.4 5.9 Alternative minimum tax 5.2 4.0 Interest expense limitation 5.6 10.2 Deferred rent liabilities 21.3 25.6 Deferred FICA liability 6.0 — Other 10.0 4.5 Total gross deferred tax assets 146.1 135.0 Intangible assets (41.7) (37.0) Fixed assets (3.1) (4.4) Contract implementation costs (7.0) (6.2) Deferred rent assets (14.8) (21.3) Less valuation allowances (5.8) (1.9) Net deferred tax assets $ 73.7 $ 64.2 At December 31, 2020, the Company had cumulative U.S. federal and state net operating loss (“NOL”) carryforwards of approximately $320.6 million and $282.0 million, respectively, which are available to offset U.S. federal and state taxable income in future periods. These amounts include net operating losses acquired through acquisitions which are subject to Section 382 of the Internal Revenue Code. The general limitation rules allow the Company to utilize the net operating losses subject to an annual limitation that is determined by multiplying the federal long-term tax-exempt rate by the Company’s value immediately before the ownership change. The federal net operating losses will start to expire in 2022. 2017 Tax Reform subjects a U.S. shareholder to tax on Global Intangible Low-Taxed Income (“GILTI”) earned by certain foreign subsidiaries. An entity can make an accounting policy election to either recognize deferred taxes for temporary basis differences expected to reverse as GILTI in future years or to provide for the tax expense related to GILTI in the year the tax is incurred. The Company has elected to recognize the tax on GILTI as a period expense in the period the tax is incurred. A valuation allowance is required to be established when, based on currently available information, it is more likely than not that all or a portion of a deferred tax asset will not be realized. The guidance on accounting for income taxes provides important factors in determining whether a deferred tax asset will be realized, including whether there has been sufficient taxable income in recent years and whether sufficient income can reasonably be expected in future years in order to utilize the deferred tax asset. Consideration is given to the weight of all available evidence, both positive and negative. The Company estimates its already contracted business growth will be profitable and allow the Company to utilize its NOL carryforwards and other deferred tax assets. Accordingly, the Company believes that it is more likely than not that the remaining deferred tax assets will be realized. Should the Company not operationally execute as expected, and the growth in business not be as profitable as expected, such realizability assessment may change. The Company has recorded valuation allowances at December 31, 2020 and 2019 of $5.8 million and $1.9 million, respectively, based on its assessment that it is more likely than not that a portion of the Company’s separate state income tax net operating loss will not be realized because the Company no longer has business activities in that state, or where the activity level has decreased to such a level where the Company believes the NOL will not be realized. In addition, the December 31, 2020 valuation allowance includes $3.7 million attributable to research and development credits, acquired from the Company’s acquisition of SCI on April 1, 2020. The 2020, 2019, and 2018 foreign current tax provision includes $2.4 million, $1.9 million, and $1.5 million, respectively, for income taxes arising from the pre-tax income of the Company’s India subsidiaries. The tax provisions are net of the impact of a tax holiday in India. The Company’s benefits from this tax holiday were $4.3 million, $2.2 million, and $1.6 million for the year ended December 31, 2020, 2019, and 2018, respectively. The tax holidays are set to expire between March 31, 2021 and March 31, 2027. The Company recognizes the tax benefit from an uncertain tax position only if it is more likely than not that the tax position will be sustained upon examination by taxing authorities, based on the technical merits of the position. The tax benefits recognized in the financial statements are measured based on the largest benefit that has a greater than fifty percent likelihood of being realized upon ultimate settlement. The Company’s unrecognized tax benefits as of December 31, 2020, 2019, and 2018 were not material. In connection with tax return examinations, contingencies can arise that generally result from different interpretations of tax laws and regulations as they pertain to the amount, timing or inclusion of revenues and expenses in taxable income, or the ability to utilize tax credits to reduce income taxes payable. While it is probable, based on the potential outcome of the Company’s federal and state tax examinations or the expiration of the statute of limitations for specific jurisdictions, that the liability for unrecognized tax benefits may increase or decrease within the next 12 months, the Company does not expect any such change would have a material effect on its financial condition, results of operations or cash flow. The Company and its subsidiaries are subject to U.S. federal income tax as well as income tax of multiple state and foreign jurisdictions. U.S. federal income tax returns for 2017 and all subsequent years are currently open for examination. State jurisdictions vary for open tax years. The statute of limitations for most states ranges from three

8.00% Series A Convertible Pref

8.00% Series A Convertible Preferred Stock	12 Months Ended
	Dec. 31, 2020
Temporary Equity Disclosure [Abstract]
8.00% Series A Convertible Preferred Stock	8.00% Series A Convertible Preferred Stock At the close of the Transaction on February 16, 2016 (as described in Note 1), the Company issued to the Investor: (i) 200,000 shares of Preferred Stock, for an aggregate price of $200 million, and (ii) a warrant with a term of ten years to acquire up to 60 million shares of common stock at an exercise price of $3.50 per share, on the terms and subject to the conditions set forth in the Warrant Agreement (“Warrant”). On January 15, 2021 the Investor converted all of its 294,266 shares (the “Current Shares”) of Preferred Stock into 117,706,400 shares of common stock of the Company into which the Current Shares were convertible pursuant to the Certificate of Designation of the Preferred Stock, and, in consideration therefor, the Company (i) issued 21,582,800 additional shares of common stock to the Investor, and (ii) paid the Investor $105.0 million in cash. On January 19, 2021, the Company filed a Certificate of Elimination of 8.00% Series A Convertible Preferred Stock with the Secretary of State of the State of Delaware to eliminate the Certificate of Designations of the 8.00% Series A Convertible Preferred Stock. Dividend Rights The holders of the Preferred Stock were entitled to receive cumulative dividends January 1, April 1, July 1, and October 1 of each year (dividend payment dates), which commenced on April 1, 2016, at a rate equal to 8% per annum (preferred dividend) multiplied by the liquidation preference per share, initially $1,000 per share adjusted for any unpaid cumulative preferred dividends. As of December 31, 2020 and 2019, the Company had accrued dividends of $5.8 million and $5.3 million associated with the Preferred Stock, respectively, of which $5.8 million and $5.3 million was paid in additional shares and $940 and $580 was paid in cash in January of the following year, respectively. For the year ended December 31, 2020 and 2019, the dividends paid, or accrued, in additional shares of Preferred Stock totaled $22.4 million and $20.7 million, respectively. The following summarizes the Preferred Stock activity for the year ended December 31, 2020 and 2019 (in millions, except per share data): Preferred Stock Shares Issued and Outstanding Carrying Value Balance at January 1, 2018 227,483 $ 189.3 Dividends paid/accrued dividends 18,750 19.1 Balance at December 31, 2018 246,233 $ 208.4 Dividends paid/accrued dividends 20,296 20.7 Balance at December 31, 2019 266,529 $ 229.1 Dividends paid/accrued dividends 21,968 22.4 Balance at December 31, 2020 288,497 $ 251.5

Earnings (Loss) Per Share

Earnings (Loss) Per Share	12 Months Ended
	Dec. 31, 2020
Earnings Per Share [Abstract]
Earnings (Loss) Per Share	Earnings (Loss) Per Share Basic net income per share is computed by dividing net income, less any dividends, accretion or decretion, redemption or induced conversion on the Preferred Stock, by the weighted average number of common shares outstanding during the period. As the Preferred Stock participates in dividends alongside the Company’s common stock (per their participating dividends), the Preferred Stock would constitute participating securities under ASC 260-10 and are applied to earnings per share using the two-class method. Under this method, all earnings (distributed and undistributed) are allocated to common shares and participating securities based on their respective rights to receive dividends. Diluted net income per share is calculated using the more dilutive of the if-converted or the two-class method. For the years ended December 31, 2020, 2019, and 2018, the two-class method was more dilutive and was computed by adjusting the denominator used in the basic net income per share computation by potentially dilutive securities outstanding during the period plus, when their effect is dilutive, incremental shares consisting of shares subject to stock options, shares issuable upon vesting of RSAs, RSUs, PBRSUs and shares issuable upon conversion of preferred stock. Basic and diluted net income (loss) per common share are calculated as follows (in millions, except share and per share data): Year Ended December 31, 2020 2019 2018 Basic EPS: Net income (loss) $ 117.1 $ 12.0 $ (45.3) Less dividends on preferred shares (22.4) (20.7) (19.1) Less income allocated to preferred shareholders (47.3) — — Net income (loss) available/(allocated) to common shareholders - basic $ 47.4 $ (8.7) $ (64.4) Diluted EPS: Net income (loss) $ 117.1 $ 12.0 $ (45.3) Less dividends on preferred shares (22.4) (20.7) (19.1) Less income allocated to preferred shareholders (37.7) — — Net income (loss) available/(allocated) to common shareholders - diluted $ 57.0 $ (8.7) $ (64.4) Basic weighted-average common shares 115,729,645 111,505,993 108,175,159 Add: Effect of dilutive equity awards 12,731,424 — — Add: Effect of dilutive warrants 46,112,201 — — Diluted weighted average common shares 174,573,270 111,505,993 108,175,159 Net income (loss) per common share (basic) $ 0.41 $ (0.08) $ (0.60) Net income (loss) per common share (diluted) $ 0.33 $ (0.08) $ (0.60) Because of their anti-dilutive effect, 97,244, 21,262,959, 25,725,761 common share equivalents comprised of stock options, RSAs, PBRSUs, and RSUs have been excluded from the diluted earnings per share calculation for the years ended December 31, 2020, 2019, and 2018, respectively. Additionally, for the years ended December 31, 2019 and 2018, warrants to acquire up to 61.5 million shares of the Company's common stock has been excluded from the diluted earnings per share calculation because they are anti-dilutive.

Commitments and Contingencies

Commitments and Contingencies	12 Months Ended
	Dec. 31, 2020
Commitments and Contingencies Disclosure [Abstract]
Commitments and Contingencies	Commitments and Contingencies Legal Proceedings Other than as described below, the Company is not presently a party to any material litigation or regulatory proceeding and is not aware of any pending or threatened litigation or regulatory proceeding against the Company which, individually or in the aggregate, could have a material adverse effect on its business, operating results, financial condition or cash flows. In May 2016, the Company was served with a False Claims Act case brought by a former emergency department service associate who worked at a hospital of one of the Company’s customers, MedStar Inc.’s Washington Hospital Center (“WHC”), along with WHC and three other hospitals that were PAS clients and a place holder, John Doe hospital, representing all PAS clients ( U.S. ex rel. Graziosi vs. Accretive Health, Inc. et. al.) , and seeking money damages, False Claims Act penalties, and plaintiff’s attorneys’ fees. The Third Amended Complaint alleges that the Company’s PAS business violates the federal False Claims Act. The case was originally filed under seal in 2013 in the federal district court in Chicago, was presented to the U.S. Attorney in Chicago, and the U.S. Attorney declined to intervene. The Company believes that it has meritorious defenses to all claims in the case and intends to vigorously defend itself against these claims. Both the Company’s and plaintiff’s motions for summary judgment were denied in December 2020, and the parties are presently conducting damages and expert discovery. Discovery and dispositive motions are expected to extend through January 2022, with trial, if necessary, in mid-to-late 2022.

Related Party Transactions

Related Party Transactions	12 Months Ended
	Dec. 31, 2020
Related Party Transactions [Abstract]
Related Party Transactions	Related Party Transactions As a result of the closing of the Transaction with Ascension Health Alliance on February 16, 2016 and Ascension Health Alliance's ownership interest in the Investor, Ascension became a related party to the Company. This note, encompasses transactions between Ascension and its affiliates, including AMITA Health, and the Company pursuant to the A&R MPSA, including all supplements, amendments and other documents entered into in connection therewith. See Note 1, Business Description and Basis of Presentation and Note 18, 8.00% Series A Convertible Preferred Stock for further discussion about the agreements with Ascension. Net services revenue from services provided to Ascension included in the Company’s consolidated statements of operations were (in millions): Year Ended December 31, 2020 2019 2018 $ 809.5 $ 790.4 $ 600.1 Amounts included in the Company's consolidated balance sheets for Ascension, excluding debt, are (in millions): December 31, 2020 December 31, 2019 Accounts receivable, net of $0.1 million and $0.0 million allowance - related party $ 30.9 $ 30.8 Accrued service costs, current $ 9.1 $ 28.9 Refund liabilities, current 0.6 1.0 Deferred revenue (contract liabilities), current 5.6 4.2 Current portion of customer liabilities 15.3 34.1 Deferred revenue (contract liabilities), non-current 16.3 18.6 Non-current portion of customer liabilities 16.3 18.6 Total customer liabilities $ 31.6 $ 52.7 Since Ascension is the Company's largest customer, a significant percentage of the Company's cost of services is associated with providing services to Ascension. However, due to the nature of the Company's global business services and information technology operations, it is impractical to assign the dollar amount associated with services provided to Ascension.

Deferred Contract Costs

Deferred Contract Costs	12 Months Ended
	Dec. 31, 2020
Deferred Costs, Capitalized, Prepaid, and Other Assets Disclosure [Abstract]
Deferred Contract Costs	Revenue Recognition Disaggregation of Revenue In the following table, revenue is disaggregated by source of revenue (in millions): Year Ended December 31, 2020 2019 2018 Net operating fees $ 1,093.8 $ 1,037.4 $ 760.2 Incentive fees 70.6 56.2 38.3 Other 106.4 92.5 70.0 Net services revenue $ 1,270.8 $ 1,186.1 $ 868.5 Contract Balances The following table provides information about receivables, contracts assets, and contract liabilities from contracts with customers (in millions): December 31, 2020 December 31, 2019 Receivables (1) $ 122.2 $ 83.1 Contract assets (2) — 2.0 Contract liabilities (2) 28.6 25.3 (1) Receivables are included in accounts receivable, net. The balance includes accounts receivable, net - related party. (2) Contract assets and contract liabilities are included in other current assets and customer liabilities, respectively. The contract liabilities balance contains related party amounts, including $5.6 million and $4.2 million of current customer liabilities and $16.3 million and $18.6 million of non-current customer liabilities for the year ended December 31, 2020 and 2019, respectively. A receivable is recognized in the period the Company provides services when the Company’s right to consideration is unconditional. Payment terms on invoiced amounts are typically 30-60 days. The Company recognized revenue of $91.6 million and $69.7 million during the year ended December 31, 2020 and 2019, which amounts were included in contract liabilities at the beginning of the respective periods. These revenue amounts include $85.0 million and $66.7 million for the year ended December 31, 2020 and 2019, respectively, related to advanced billings which become accounts receivable and contract liabilities on the first day of the respective service period. Transaction Price Allocated to the Remaining Performance Obligation The following table includes estimated revenue expected to be recognized in the future related to performance obligations that are unsatisfied (or partially unsatisfied) at the end of the reporting period (in millions). The estimated revenue does not include amounts of variable consideration that are constrained. Net operating fees Incentive fees Other 2021 $ 112.6 $ 4.1 $ 3.7 2022 62.3 17.6 5.7 2023 48.0 — 5.7 2024 27.5 — 5.7 2025 18.3 — 2.9 Thereafter 12.7 — — Total $ 281.4 $ 21.7 $ 23.7 The amounts presented in the table above include variable fee estimates for the non-cancellable term of the Company's physician groups RCM services contracts, fixed fees which are typically recognized ratably as the performance obligation is satisfied, and incentive fees which are measured cumulatively over the contractually defined performance period. Estimates of revenue expected to be recognized in future periods also exclude unexercised customer options to purchase services within the Company's PAS contracts that do not represent material rights to the customer. Customer options that do not represent a material right are only accounted for in accordance with Topic 606 when the customer exercises its option to purchase additional goods or services. The Company does not disclose information about remaining performance obligations with an original expected duration of one year or less. The Company has elected certain of the optional exemptions from the disclosure requirement for remaining performance obligations for specific situations in which an entity need not estimate variable consideration to recognize revenue. Accordingly, the Company applies a practical expedient to its modular RCM services and does not disclose information about variable consideration from remaining performance obligations when the Company has a right to consideration from a customer in an amount that corresponds directly with the value to the customer of the entity's performance completed to date. PAS performance obligations are typically short in duration (often less than 1 day) with any uncertainty related to the associated variable consideration resolved as each increment of service (completion of a level of care review or an appeal) is completed which reflects the value the customer receives from the Company’s fulfillment of the performance obligation. Modular RCM services performance obligations for variable consideration are of short duration with fees corresponding to the value the customer has realized, for example, patient accounts collected on behalf of the customer or medical record lines transcribed. For end-to-end RCM contracts, the Company does not disclose information about remaining, wholly unsatisfied performance obligations for variable consideration that the Company is able to allocate to one or more, but not all, of the performance obligations in its contracts. The Company’s end-to-end RCM services performance obligations are satisfied over time and are substantially the same from period to period under either a co-managed or operating partner model. Fees are variable and consist of net operating fees and incentive fees, with the uncertainty related to net operating fees and certain incentive fees being resolved quarterly, and with the uncertainty of other incentive fees being resolved annually. The information presented in the table above includes estimates for incentive fees where the uncertainty related to the final fee is resolved on longer than a quarterly basis and to the extent the Company does not believe the associated consideration is constrained. December 31, 2020 December 31, 2019 Prepaid expenses and other current assets $ 4.5 $ 4.0 Other assets 19.6 20.8 Total deferred contract costs $ 24.1 $ 24.8

Segments and Customer Concentra

Segments and Customer Concentrations	12 Months Ended
	Dec. 31, 2020
Segment Reporting [Abstract]
Segments and Customer Concentrations	Segments and Customer Concentrations The Company has determined that it has a single operating segment in accordance with how its business activities are managed and evaluated. All of the Company’s significant operations are organized around the single business of providing end-to-end management services of revenue cycle operations for U.S.-based healthcare providers. Accordingly, for purposes of segment disclosures, the Company has only one reportable segment. Healthcare providers affiliated with Ascension have accounted for a significant portion of the Company’s net services revenue each year since the Company’s formation. For the year ended December 31, 2020, 2019, and 2018, net services revenue from healthcare organizations affiliated with Ascension accounted for 64%, 67%, and 69% of the Company's total net services revenue, respectively. The loss of customers within the Ascension health system would have a material adverse impact on the Company’s operations. For the year ended December 31, 2020, 2019, and 2018, Intermountain Healthcare accounted for 14%, 15%, and 14% of the Company's total net services revenue, respectively.

Derivative Financial Instrument

Derivative Financial Instruments	12 Months Ended
	Dec. 31, 2020
Derivative Instruments and Hedging Activities Disclosure [Abstract]
Derivative Financial Instruments	Derivative Financial Instruments The Company utilizes cash flow hedges to mitigate its currency risk arising from its global delivery resources and to reduce variability in interest cash flows from its outstanding debt. As of December 31, 2020, the Company has recorded $0.4 million of existing gains and $2.3 million of existing losses in accumulated other comprehensive income for the foreign currency hedges and interest rate swaps, respectively. The Company estimates that $0.4 million of gains and $1.4 million of losses reported in accumulated other comprehensive income are expected to be reclassified into earnings within the next 12 months for the foreign currency hedges and interest rate swaps, respectively. The amounts related to foreign currency hedges that were reclassified into cost of services were a net loss of $0.8 million and a net gain of $1.3 million for the years ended December 31, 2020 and 2019, respectively. The amounts related to the interest rate swaps that was reclassified into interest expense were a net loss of $1.4 million and a net gain of $0.2 million for the years ended December 31, 2020 and 2019. The Company classifies cash flows from its derivative programs as cash flows from operating activities in the consolidated statements of cash flows. As of December 31, 2020, the Company’s currency forward contracts have maturities extending no later than December 31, 2021 and the Company's interest rate swaps extend no later than August of 2022. As of December 31, 2020, the notional amounts of the Company's open foreign currency forward contracts and interest rate swaps were approximately $55.9 million and $200.0 million, respectively. As of December 31, 2019, the notional amounts of the Company's open foreign currency forward contracts and interest rate swaps were approximately $52.6 million and $100.0 million, respectively. As of December 31, 2020, the Company held no derivatives, or non-derivative hedging instruments, that were designated in fair value or net investment hedges.

Retirement Plan

Retirement Plan	12 Months Ended
	Dec. 31, 2020
Retirement Benefits [Abstract]
Retirement Plan	Retirement Plan The Company maintains a 401(k) retirement plan (the “401(k) plan”) that is intended to be a tax-qualified defined contribution plan under Section 401(k) of the Internal Revenue Code. In general, all employees are eligible to participate. In conjunction with the acquisition of Intermedix Holdings, Inc., the company continued to maintain the pre-existing Intermedix 401(k) retirement plan (“Intermedix 401(k) plan”). Both 401(k) plans include a salary deferral arrangement pursuant to which participants may elect to reduce their current compensation by up to the statutorily prescribed limit, equal to $19,500 in 2020, $19,000 in 2019, and $18,500 in 2018, and have the amount of the reduction contributed to the 401(k) plan. The Company currently matches employee contributions up to 50% of the first 6% of base compensation that a participant contributes to the 401(k) plan, including director-level and above employees. For the years ended December 31, 2020, 2019, and 2018, total Company contributions to the 401(k) plan were $2.9 million, $6.6 million, and $5.2 million, respectively. The Company matches 100% of employee contributions on the first 1% of deferrals and 50% of the next 5% that a participant contributes to the Intermedix 401(k) plan. For the years ended December 31, 2020 and 2019, total Company contributions to the Intermedix 401(k) plan were $0.7 million and $1.7 million, respectively. From the acquisition date, total Company contributions to the Intermedix 401(k) plan were $1.1 million for the year ended December 31, 2018. In response to the COVID-19 pandemic, the Company announced several temporary cost reduction actions, including the suspension of matching contributions to the 401(k) plans effective May 29, 2020 for exempt associates and June 5, 2020 for hourly associates. However, participants were able to continue making salary deferral contributions to the 401(k) plans. The 401(k) match was reinstated for both plans effective January 1, 2021 on a prospective basis.

Prepaid Expenses and Other Curr

Prepaid Expenses and Other Current Assets	12 Months Ended
	Dec. 31, 2020
Deferred Costs, Capitalized, Prepaid, and Other Assets Disclosure [Abstract]
Prepaid Expenses and Other Current Assets	Prepaid Expenses and Other Current Assets Prepaid expenses and other current assets is comprised of the following (in millions): Year Ended December 31, 2020 2019 Acquisition and disposition contingent assets $ 19.5 $ — Prepaid expenses 18.2 16.7 Deferred contract costs 4.5 4.0 Base fee discounts 3.8 2.6 Lease-related receivables — 4.3 Other current assets 13.4 14.0 Ending balance $ 59.4 $ 41.6

Other Assets

Other Assets	12 Months Ended
	Dec. 31, 2020
Deferred Costs, Capitalized, Prepaid, and Other Assets Disclosure [Abstract]
Other Assets	Other AssetsOther assets is comprised of the following (in millions): Year Ended December 31, 2020 2019 Deferred contract costs $ 19.6 $ 20.8 Base fee discounts 18.1 8.2 Acquisition and disposition contingent assets 10.8 — Prepaid expenses 5.9 4.2 Other assets 6.6 1.8 Ending balance $ 61.0 $ 35.0

Accrued Expenses and Other Curr

Accrued Expenses and Other Current Liabilities	12 Months Ended
	Dec. 31, 2020
Payables and Accruals [Abstract]
Accrued Expenses and Other Current Liabilities	Accrued Expenses and Other Current Liabilities Other accrued expenses is comprised of the following (in millions): Year Ended December 31, 2020 2019 Accrued expenses $ 33.2 $ 30.0 Acquisition deferred payments 22.0 — Notes payable 1.9 8.0 Other current liabilities 2.6 2.0 Ending balance $ 59.7 $ 40.0

Subsequent Event

Subsequent Event	12 Months Ended
	Dec. 31, 2020
Subsequent Events [Abstract]
Subsequent Event	Subsequent EventOn January 15, 2021, the Investor converted its 8% Series A Convertible Preferred Stock. See Note 18. 8% Series A Convertible Preferred Stock for more information.

Summary of Significant Accoun_2

Summary of Significant Accounting Policies (Policies)	12 Months Ended
	Dec. 31, 2020
Accounting Policies [Abstract]
Basis of Presentation	Basis of PresentationThe consolidated financial statements include the assets, liabilities and results of operations of the Company and its wholly owned subsidiaries. All material intercompany transactions and balances have been eliminated in consolidation. The preparation of financial statements in conformity with the United States generally accepted accounting principles (“GAAP”) requires management to make estimates and assumptions that affect the amounts reported in these consolidated financial statements and accompanying notes. Actual results can differ from those estimates.
Segments	SegmentsReporting segments are identified as components of an enterprise about which separate discrete financial information is available and is evaluated by the chief operating decision maker, or decision-making group, relating to resource allocation and performance assessments. All of the Company’s significant operations are organized around the single business of providing revenue cycle operations for healthcare providers. The Company views its operations and manages its business as one operating and reportable segment.
Revenue Recognition	Revenue Recognition The Company's primary source of revenue is its end-to-end RCM services fees. The Company also generates revenue through modular RCM services, where customers will engage the Company for only specific components of its end-to-end RCM service offering on a fixed-fee or transactional basis. Revenue Cycle Management RCM services fees are primarily variable and performance related, and are generally viewed as the consideration earned in satisfaction of a single performance obligation which is considered a series. Variable consideration for end-to-end RCM services are allocated to and recognized over the related time period as the amounts reflect the consideration the Company is entitled to and relate specifically to the Company’s efforts to satisfy its performance obligation. Fees for physician group RCM services include variable consideration contingent on customer collections, and inputs to the Company’s revenue estimates typically include historical service fees and historical customer collection amounts. RCM services fees consist of net operating fees, incentive fees, and other fees. Net Operating Fees The Company’s net operating fees consist of: i) gross base fees invoiced to customers; less ii) corresponding costs of customers’ revenue cycle operations which the Company pays pursuant to its RCM agreements, including salaries and benefits for the customers' RCM personnel, and related third-party vendor costs; plus iii) fees accrued for physician group RCM services. The Company recognizes revenue related to net operating fees ratably as the performance obligation for the RCM services is satisfied. Base fees are typically billed in advance of the quarter and paid in three monthly payments as the entity performs and the customer simultaneously receives and consumes the benefits of the services provided. The costs of customers’ revenue cycle operations, which the Company pays pursuant to its RCM agreements, are accrued based on the service period. Net operating fees for physician groups are invoiced on a monthly basis and payment terms are typically 30 days. Incentive Fees Incentive fees are structured to reflect quarterly or annual performance and are evaluated on a contract-by-contract basis. The Company estimates incentive fee revenue based on contractually agreed-upon financial or operating metrics. The Company recognizes revenue related to incentive fees ratably as the performance obligation for RCM services is satisfied, to the extent that it is probable that a significant reversal of cumulative revenue will not occur once the uncertainty is resolved. Incentive fees are typically billed and paid on a quarterly basis. Other The Company recognizes revenue related to other RCM fees as RCM services are provided. These services consist of an obligation to provide a specific component of its end-to-end RCM service offering. Fees are typically variable in nature with the entire amount being included in revenue in the month of service. The customer simultaneously receives and consumes the benefits provided by the services and the fees are typically billed on a monthly basis and payment terms are typically 30 days. To the extent that certain service fees are fixed and not subject to refund, adjustment, or concession, these fees are generally recognized into revenue ratably as the performance obligation is satisfied. The Company recognizes revenue from PAS in the period in which the service is performed. The Company’s PAS arrangements typically consist of an obligation to provide specific services to customers on an if and when needed basis. These services are provided under a fixed price per unit arrangement. Fees for the Company's PAS arrangements are typically billed on a monthly basis with 30 to 60 day payment terms. PM services arrangements include a single performance obligation, constituting a series, to manage and administer various non-clinical aspects of a customer's physician practice, which may be comprised of numerous physical office locations. Consideration for PM services is typically variable in nature and allocated to and recognized over the related time period as the amounts reflect the consideration the Company is entitled to and relate specifically to the Company’s effort to satisfy its performance obligation. PM services fees are invoiced on a monthly basis and payment terms are typically 30 days. Bundled Services Modular RCM services may be sold separately or bundled in a contract. End-to-end RCM services are typically sold separately but may be bundled with PAS. PAS are commonly sold separately. The typical length of an end-to-end RCM contract is two one For bundled arrangements, the Company accounts for individual services as a separate performance obligation if a service is separately identifiable from other items in the bundled arrangement and if a customer can benefit from it on its own or with other resources that are readily available to the customer. The transaction price is allocated between separate services in a bundle based on their relative standalone selling prices. The standalone selling prices are determined based on the prices at which the Company separately sells its modular services. PAS are provided at a customer’s election but do not represent material rights as the services are priced at standalone selling price throughout the life of the agreement. Cost of Services Costs associated with generating the Company’s net services revenue, including the cost of operating its global business services centers, are expensed as incurred, with the exception of deferred contract costs, which are discussed further in Note 22. Cost of services consist of (i) on-site personnel and technology costs, (ii) global business services costs, and (iii) other costs. On-site personnel and technology costs consist primarily of wages, bonuses, benefits, share-based compensation, travel, and other costs associated with employees who are assigned to customer sites to help manage the Company’s customers’ revenue cycle operations. The other significant portion of such expenses is an allocation of the costs associated with maintaining, improving, and deploying our integrated proprietary technology suite. Global business services costs relate to the Company’s global business services centers in the U.S. and internationally that perform patient scheduling and pre-registration, medical transcription, cash posting, reconciliation of payments to billing records, patient follow-up, and Medicaid eligibility determination for our customers. The Company incurs expenses related to salaries and benefits for employees in its global business services centers and non-payroll costs associated with operating its global business services centers. Other expenses consist of costs related to managing other services. These expenses consist primarily of wages, bonuses, benefits, share-based compensation, and facilities costs.
Comprehensive Income (Loss)	Comprehensive Income (Loss) Comprehensive income (loss) is the net income (loss) of the Company combined with other changes in stockholders’ equity (deficit) not involving ownership interest changes. For the Company, such changes are foreign currency translation adjustments and changes in derivatives designated as cash flow hedges.
Cash and Cash Equivalents	Cash and Cash EquivalentsThe Company considers all highly liquid investments with a maturity of three months or less when purchased to be cash equivalents.
Restricted Cash Equivalents	Restricted Cash EquivalentsIn 2020 and 2019, restricted cash equivalents represent the amount of cash or certificate of deposits (“CDs”) that the Company is unable to access for operational purposes as it collateralizes certain Company expenses or derivatives.
Accounts Receivable and Allowance for Credit Losses	Accounts Receivable and Allowance for Credit Losses Accounts receivable is comprised of unpaid balances pertaining to modular services and end-to-end RCM services, net receivable balances for end-to-end RCM customers after considering cost reimbursements owed to such customers, including related accrued balances, and amounts due from physician RCM and practice management customers. The Company evaluates its accounts receivable for expected credit losses quarterly. The Company maintains an estimated allowance for credit losses to reduce its accounts receivable to the amount that it believes will be collected. This allowance is based on the Company’s historical experience, its assessment of each customer’s ability to pay, the length of time a balance has been outstanding, input from key Company resources assigned to each customer, the status of any ongoing operations with each applicable customer, and environmental factors such as significant shifts in the healthcare environment which the Company believes may have impacted or will impact its customers’ financial health and ability to pay.
Property, Equipment and Software	Property, Equipment and Software Property, equipment and software are stated at cost, and related depreciation and amortization are calculated on the straight-line method over the estimated useful lives of the assets.
Goodwill	GoodwillGoodwill represents the difference between the purchase price of acquired companies and the related fair value of the net assets acquired, which is accounted for by the acquisition method of accounting. The Company annually tests goodwill for impairment on the first day of its fiscal fourth quarter, or more frequently if an event occurs or circumstances change that would more likely than not reduce the fair value below its carrying value. The goodwill impairment test consists of a qualitative assessment of impairment indicators, followed by, if necessary, a quantitative assessment comparing the carrying amount to the reporting unit's fair value. To the extent that the carrying value exceeds the fair value, and impairment charge would be recorded. The Company has determined there to be one reporting unit, consistent with its single operating and reportable segment.
Impairment of Long-Lived Assets	Impairment of Long-Lived AssetsProperty, equipment, software, right-of-use (“ROU”) assets, deferred contract costs, and other acquired intangible assets are reviewed for impairment whenever events or changes in circumstances indicate that the carrying amount of the asset may not be recoverable. If circumstances require a long-lived asset or asset group be reviewed for possible impairment, the Company first compares undiscounted cash flows expected to be generated by each asset or asset group to its carrying value. If the carrying value of the long-lived asset or asset group is not recoverable on an undiscounted cash flow basis, an impairment charge is recognized to the extent that the carrying value exceeds the fair value.
Accrued Compensation and Benefits	Accrued Compensation and BenefitsAccrued compensation and benefits consists of accrued payroll, bonus, paid time off, health benefits, severance, and compensation and benefits related taxes. Deferred FICA taxes are split between accrued compensation and benefits and other non-current liabilities based on their due date.
Income Taxes	Income Taxes Income taxes are accounted for under the asset and liability method. Deferred tax assets and liabilities are recognized for the future tax consequences attributable to differences between the financial statement carrying amounts of existing assets and liabilities and their respective tax basis and operating loss and tax credit carry forwards. Deferred tax assets and liabilities are measured using current tax laws and enacted tax rates in effect for the years in which those temporary differences are expected to be recovered or settled. The effect on deferred tax assets and liabilities of a change in tax rates is recognized in income in the period that includes the enactment date. The Company records a valuation allowance for deferred tax assets if, based upon the weight of all available evidence, both positive and negative, it is more likely than not that some or all of the deferred tax assets will not be realized. The Company recognizes the tax benefit from an uncertain tax position only if it is more likely than not that the tax position will be sustained upon examination by the relevant tax authorities, based on the technical merits of the position. The tax benefits recognized in the consolidated financial statements from such a position are measured based on the largest amount of benefit that has a greater than 50% percent likelihood of being realized upon ultimate settlement. Interest and penalties relating to income taxes are recognized in our income tax provision in the consolidated statements of operations and comprehensive income (loss).
Legal and Other Contingencies	Legal and Other Contingencies In the normal course of business, the Company is subject to regulatory investigations or legal proceedings, as well as demands, claims and threatened litigation. The Company records an estimated loss for any claim, lawsuit, investigation or proceeding when it is probable that a liability has been incurred and the amount of the loss can be reasonably estimated. Significant judgment is required in both the determination of the probability and whether the loss can be reasonably estimated. Actual expenses could differ from such estimates.
Foreign Currency Translation and Transaction Gains (Losses)	Foreign Currency Translation and Transaction Gains (Losses) Assets and liabilities of non-U.S. subsidiaries that operate in a local currency environment, where such local currency is the functional currency, are translated to U.S. dollars at exchange rates in effect at the balance sheet date. Income and expense accounts are translated at average exchange rates during the year which approximates the rates in effect at the transaction dates. The resulting translation adjustments are recorded as a separate component of accumulated other comprehensive income (loss).
Share-Based Compensation Expense	Share-Based Compensation Expense The Company determines the expense for all employee share-based compensation awards by estimating their fair value and recognizing such value as an expense, on a ratable basis, in the consolidated financial statements over the requisite service period in which the employees earn the awards. Performance based stock awards are recognized in expense when the performance metrics are probable to be achieved. Changes in the estimate of achievement of the performance metrics are recognized in the period of the change through a cumulative catch-up. The Company assesses the performance metrics in its awards on a quarterly basis to determine if a cumulative catch-up is necessary. The fair value of stock options is calculated using the Black-Scholes option pricing model and, for market condition stock awards, the fair value is estimated using Monte Carlo simulations. To determine the fair value of a share-based award using the Black-Scholes option pricing model, the Company makes assumptions regarding the risk-free interest rate, expected future volatility and expected life of the award. These inputs are subjective and generally require significant analysis and judgment to develop. The Company aggregates all employees into one pool based on the grant date for valuation purposes. The risk-free rate is based on the U.S. treasury yield curve in effect at the time of grant. The Company estimates the expected volatility of the share price by reviewing the historical volatility levels of its common stock in conjunction with that of public companies that operate in similar industries or are similar in terms of stage of development or size and then projecting this information toward its future expected volatility. The Company exercises judgment in selecting these companies, as well as in evaluating the available historical and implied volatility for these companies. The Company calculates the expected term in years for each stock option using a simplified method based on the average of each option’s vesting term and original contractual term. The simplified method was used due to the lack of sufficient historical data available to provide a reasonable basis upon which to estimate the expected term of each stock option. To determine the fair value of a share-based award using Monte Carlo simulations, the Company makes assumptions regarding the risk-free interest rate, expected future volatility, expected dividend yield and performance period. The risk-free rate is based on the U.S. treasury yield curve in effect at the time of grant. The Company estimates the expected volatility of the share price by reviewing the historical volatility levels of its common stock in conjunction with that of public companies that operate in similar industries or are similar in terms of stage of development or size and then projecting this information toward its future expected volatility. Dividend yield is determined based on the Company’s future plans to pay dividends. The Company had no plans to pay dividends at December 31, 2020. The Company calculates the performance period based on the specific market condition to be achieved and derived from historical data and estimates of future performance. The Company recognizes compensation expense using a straight-line method over the applicable service or performance period. During each quarter, the share-based compensation expense is adjusted to reflect forfeitures during the period; however, compensation expense already recognized is not adjusted if market conditions are not met.
Derivative Financial Instruments	Derivative Financial Instruments The Company is actively managing the risk of changes in foreign currency exchange rates and change in interest rates through foreign currency forward contracts and interest rate swap contracts traded in over-the-counter markets governed by International Swaps and Derivatives Association, Inc. (ISDA) agreements. Derivative transactions are governed by a uniform set of policies and procedures covering areas such as authorization, counterparty exposure and hedging practices. Positions are monitored using techniques such as market value and sensitivity analyses. The Company does not enter into derivative transactions for trading purposes. In order for a derivative to qualify for hedge accounting, the derivative must be formally designated as a cash flow hedge by documenting the relationship between the derivative and the hedged item. The documentation includes a description of the hedging instrument, the hedged item, the risk being hedged, the Company’s risk management objective and strategy for undertaking the hedge, and the method for assessing the effectiveness of the hedge. Additionally, the hedge relationship must be expected to be highly effective at offsetting changes in the cash flows of the hedged item at both inception of the hedge and on an ongoing basis. Prospective and retrospective hedge effectiveness will be assessed by a comparison of the critical terms of the hedging instrument and the hedged transaction. In the event that the Company’s ongoing assessment demonstrates that the critical terms of the hedging instrument or the hedged transaction have changed and no longer match, hedge effectiveness is assessed by use of a Hypothetical Derivative Method, which assesses hedge effectiveness based on a comparison of the change in fair value of the actual derivative designated as the hedging instrument and the change in fair value of a perfectly effective hypothetical derivative. The perfectly effective hypothetical derivative would have terms that identically match the critical terms of the hedged item.
Treasury Stock	Treasury Stock The Company records treasury stock at the cost to acquire such shares, including commissions paid to brokers. Treasury stock is included as a component of stockholders’ equity.
Earnings (Loss) Per Share	Earnings (Loss) Per Share Basic net income per share is computed by dividing net income, less any dividends, accretion or decretion, redemption or induced conversion on the Preferred Stock, by the weighted average number of common shares outstanding during the period. As the Preferred Stock (as defined in Note 14) participates in dividends alongside the Company’s common stock (per their participating dividends), the Preferred Stock would constitute participating securities under ASC 260-10 and are applied to earnings per share using the two-class method. Under this method, all earnings (distributed and undistributed) are allocated to common shares and participating securities based on their respective rights to receive dividends. Diluted net income per share is calculated using the more dilutive of the if-converted or the two-class method. For the year ended December 31, 2020 and 2019, the two-class method was more dilutive and was computed by adjusting the denominator used in the basic net income per share computation by potentially dilutive securities outstanding during the period plus, when their effect is dilutive, incremental shares consisting of shares subject to stock options, shares issuable upon vesting of restricted stock awards (“RSAs”), restricted stock units (“RSUs”), performance-based restricted stock units (“PBRSUs”), and shares issuable upon conversion of preferred stock.
Recently Issued Accounting Standards and Disclosures	Recently Issued Accounting Standards and DisclosuresIn June 2016, the FASB issued ASU 2016-13, Financial Instruments - Credit Losses (Topic 326): Measurement of Credit Losses on Financial Instruments (“ASU 2016-13”). ASU 2016-13 replaces the existing incurred loss impairment model with an expected loss model which requires the use of forward-looking information to calculate credit loss estimates. The change will result in earlier recognition of credit losses. The Company adopted ASU 2016-13 effective January 1, 2020 utilizing a modified retrospective transition method. Adoption of the new standard resulted in the recording of additional allowance for credit losses of $1.1 million and a corresponding impact to retained earnings and deferred tax assets.
Fair Value of Financial Instruments	Fair Value of Financial InstrumentsThe Company records its financial assets and liabilities at fair value. The accounting standard for fair value (i) defines fair value as the price that would be received to sell an asset or paid to transfer a liability (an exit price) in an orderly transaction between market participants at the measurement date, (ii) establishes a framework for measuring fair value, (iii) establishes a hierarchy of fair value measurements based upon the ability to observe inputs used to value assets and liabilities, (iv) requires consideration of nonperformance risk and (v) expands disclosures about the methods used to measure fair value. The accounting standard establishes a three-level hierarchy of measurements based upon the reliability of observable and unobservable inputs used to arrive at fair value. Observable inputs are independent market data, while unobservable inputs reflect the Company’s assumptions about valuation. The three levels of the hierarchy are defined as follows: • Level 1: Observable inputs such as quoted prices in active markets for identical assets and liabilities; • Level 2: Inputs other than quoted prices that are observable for the asset or liability, either directly or indirectly. These include quoted prices for similar assets or liabilities in active markets and quoted prices for identical or similar assets or liabilities in markets that are not active, and model-derived valuations in which all significant inputs and significant value drivers are observable in active markets; and • Level 3: Valuations derived from valuation techniques in which one or more significant inputs or significant value drivers are unobservable. The carrying amounts of the Company’s financial instruments, which include financial assets such as cash and cash equivalents, restricted cash equivalents, accounts receivable, net, and certain other current assets, as well as financial liabilities such as accounts payable, accrued service costs, accrued compensation and benefits and certain other accrued expenses, approximate their fair values, due to the short-term nature of these instruments. See Note 24, Derivative Financial Instruments, for a discussion of the fair value of the Company's forward currency derivative contracts and interest rate swaps.

Summary of Significant Accoun_3

Summary of Significant Accounting Policies (Tables)	12 Months Ended
	Dec. 31, 2020
Accounting Policies [Abstract]
Schedule of Property, Equipment and Software and Useful Lives	The major classifications of property, equipment and software and their expected useful lives are as follows: Buildings and land 30 to 42 years and indefinite Computers and other equipment 3 to 5 years Leasehold improvements Shorter of 10 years or lease term Office furniture 5 years Software 3 to 5 years

Acquisitions (Tables)

Acquisitions (Tables)	12 Months Ended
	Dec. 31, 2020
Business Combinations [Abstract]
Schedule of Fair Value of Assets Acquired and Liabilities Assumed	The fair value of assets acquired and liabilities assumed is (in millions): Purchase Price Allocation Total purchase consideration $ 196.7 Allocation of consideration to assets acquired and liabilities assumed: Cash and cash equivalents $ 2.9 Accounts receivable 2.8 Prepaid expenses and other current assets 1.1 Property, equipment and software 0.3 Operating lease right-of-use assets 1.2 Intangible assets 86.1 Goodwill 125.6 Accounts payable (0.2) Current portion of customer liabilities (4.0) Accrued compensation and benefits (1.6) Current portion of operating lease liabilities (0.5) Other accrued expenses (0.4) Non-current portion of operating lease liabilities (0.7) Other non-current liabilities (5.0) Deferred income tax liabilities (10.9) Net assets acquired $ 196.7
Schedule of Pro Forma Results	The following table summarizes, on a pro forma basis, the combined results of the Company as though the SCI and RevWorks acquisitions had occurred as of January 1, 2019. These pro forma results are not necessarily indicative of either the actual consolidated results had the acquisitions occurred as of January 1, 2019 or of the future consolidated operating results. Pro forma results are (in millions): Year Ended December 31, 2020 2019 Net services revenue $ 1,320.9 $ 1,297.7 Net income (loss) $ 115.7 $ (1.6)

Accounts Receivable and Allow_2

Accounts Receivable and Allowance for Credit Losses (Tables)	12 Months Ended
	Dec. 31, 2020
Receivables [Abstract]
Schedule of Allowance for Doubtful Accounts	Movements in the allowance for credit losses are as follows (in millions): Year Ended December 31, 2020 2019 Beginning balance $ 2.8 $ 1.1 Cumulative effect of ASC 326 adoption 1.1 — Provision (recoveries) 0.6 3.1 EMS Disposition (0.6) — Write-offs (0.1) (1.4) Ending balance $ 3.8 $ 2.8

Property, Equipment and Softw_2

Property, Equipment and Software (Tables)	12 Months Ended
	Dec. 31, 2020
Property, Plant and Equipment [Abstract]
Schedule of Property, Equipment and Software	Property, equipment and software consist of the following (in millions): December 31, 2020 December 31, 2019 Buildings and land $ 4.6 $ 4.6 Computer and other equipment 55.0 50.7 Leasehold improvements 23.2 31.1 Software 135.7 123.0 Office furniture 6.4 9.4 Property, equipment and software, gross 224.9 218.8 Less accumulated depreciation and amortization (131.2) (101.9) Property, equipment and software, net $ 93.7 $ 116.9
Summary Depreciation and Amortization Expense	The following table summarizes the allocation of depreciation and amortization expense between cost of services and selling, general and administrative expenses (in millions): Year Ended December 31, 2020 2019 2018 Cost of services $ 46.6 $ 37.8 $ 23.9 Selling, general and administrative 4.0 4.0 4.3 Total depreciation and amortization $ 50.6 $ 41.8 $ 28.2

Leases (Tables)

Leases (Tables)	12 Months Ended
	Dec. 31, 2020
Leases [Abstract]
Schedules of Components of Lease Costs and Supplemental Cash Flow Information	The components of lease costs are as follows (in millions): Year Ended December 31, 2020 2019 Operating lease cost $ 18.2 $ 19.1 Finance lease cost: Amortization of ROU assets 0.4 0.8 Interest on lease liabilities 0.1 0.1 Sublease income (2.2) (2.2) Total lease cost $ 16.5 $ 17.8 Supplemental cash flow information related to leases are as follows (in millions): Year Ended December 31, 2020 2019 Cash paid for amounts included in the measurement of lease liabilities: Operating cash flows for operating leases $ 20.7 $ 18.7 Operating cash flows for finance leases 0.1 0.1 Financing cash flows for finance leases 0.8 0.8 ROU assets obtained in exchange for lease obligations: Operating leases 3.3 17.3 Finance leases — 0.7
Schedule of Supplemental Balance Sheet Information	Supplemental balance sheet information related to leases are as follows: December 31, 2020 December 31, 2019 Weighted average remaining lease term: Operating leases 7 years 8 years Finance leases 2 years 2 years Weighted average incremental borrowing rate: Operating leases 8.94 % 8.84 % Finance leases 6.62 % 6.45 %
Schedule of Operating Lease Maturity	Maturities of lease liabilities as of December 31, 2020 are as follows (in millions): Operating Leases Finance Leases 2021 $ 18.7 $ 0.5 2022 16.1 0.1 2023 15.3 — 2024 15.0 — 2025 14.8 — Thereafter 34.0 — Total 113.9 0.6 Less: Imputed interest 30.7 — Present value of lease liabilities $ 83.2 $ 0.6
Schedule of Finance Lease Maturity	Maturities of lease liabilities as of December 31, 2020 are as follows (in millions): Operating Leases Finance Leases 2021 $ 18.7 $ 0.5 2022 16.1 0.1 2023 15.3 — 2024 15.0 — 2025 14.8 — Thereafter 34.0 — Total 113.9 0.6 Less: Imputed interest 30.7 — Present value of lease liabilities $ 83.2 $ 0.6

Intangible Assets (Tables)

Intangible Assets (Tables)	12 Months Ended
	Dec. 31, 2020
Goodwill and Intangible Assets Disclosure [Abstract]
Schedule of Intangible Assets	The following table provides the gross carrying value and accumulated amortization for each major class of intangible asset at December 31, 2020 and December 31, 2019 (in millions): December 31, 2020 December 31, 2019 Gross Carrying Value Accumulated Amortization Net Book Value Gross Carrying Value Accumulated Amortization Net Book Value Customer relationships $ 97.7 $ (14.7) $ 83.0 $ 160.9 $ (15.6) $ 145.3 Technology 101.7 (13.6) 88.1 26.8 (7.4) 19.4 Total intangible assets $ 199.4 $ (28.3) $ 171.1 $ 187.7 $ (23.0) $ 164.7 The Company acquired the following intangible assets in 2020 (in millions, except weighted average useful life): Weighted Average Useful Life Gross Carrying Value Customer relationships 10 years $ 5.6 Technology 10 years $ 85.3
Schedule of Estimated Annual Amortization Expense	Estimated annual amortization expense related to intangible assets with definite lives as of December 31, 2020 is as follows (in millions): 2021 $ 17.3 2022 17.3 2023 17.3 2024 15.5 2025 14.5 Thereafter 89.2 Total $ 171.1

Goodwill (Tables)

Goodwill (Tables)	12 Months Ended
	Dec. 31, 2020
Goodwill and Intangible Assets Disclosure [Abstract]
Schedule of Changes in Carrying Amount of Goodwill	Changes in the carrying amount of goodwill for the year ended December 31, 2020 were (in millions): Goodwill Balance as of December 31, 2019 $ 253.2 Acquisitions 129.2 EMS Disposition (7.1) Balance as of December 31, 2020 $ 375.3

Revenue Recognition (Tables)

Revenue Recognition (Tables)	12 Months Ended
	Dec. 31, 2020
Revenue from Contract with Customer [Abstract]
Schedule of Disaggregated Revenue By Source	In the following table, revenue is disaggregated by source of revenue (in millions): Year Ended December 31, 2020 2019 2018 Net operating fees $ 1,093.8 $ 1,037.4 $ 760.2 Incentive fees 70.6 56.2 38.3 Other 106.4 92.5 70.0 Net services revenue $ 1,270.8 $ 1,186.1 $ 868.5
Schedule of Assets and Liabilities	The following table provides information about receivables, contracts assets, and contract liabilities from contracts with customers (in millions): December 31, 2020 December 31, 2019 Receivables (1) $ 122.2 $ 83.1 Contract assets (2) — 2.0 Contract liabilities (2) 28.6 25.3 (1) Receivables are included in accounts receivable, net. The balance includes accounts receivable, net - related party.
Schedule of Transaction Price Allocated to the Remaining Performance Obligation	The following table includes estimated revenue expected to be recognized in the future related to performance obligations that are unsatisfied (or partially unsatisfied) at the end of the reporting period (in millions). The estimated revenue does not include amounts of variable consideration that are constrained. Net operating fees Incentive fees Other 2021 $ 112.6 $ 4.1 $ 3.7 2022 62.3 17.6 5.7 2023 48.0 — 5.7 2024 27.5 — 5.7 2025 18.3 — 2.9 Thereafter 12.7 — — Total $ 281.4 $ 21.7 $ 23.7

Customer Liabilities (Tables)

Customer Liabilities (Tables)	12 Months Ended
	Dec. 31, 2020
Other Liabilities Disclosure [Abstract]
Schedule of Customer Liabilities	Customer liabilities consist of the following (in millions): December 31, 2020 December 31, 2019 Accrued service costs, current $ 12.2 $ 33.3 Collections payable to clients, current 4.6 5.4 Customer deposits, current — 1.7 Refund liabilities, current 2.9 1.0 Deferred revenue (contract liabilities), current 12.3 6.7 Current portion of customer liabilities (1) 32.0 48.1 Deferred revenue (contract liabilities), non-current 16.3 18.6 Non-current portion of customer liabilities (1) 16.3 18.6 Total customer liabilities $ 48.3 $ 66.7 (1) Current and non-current portion of customer liabilities include amounts for a related party. See Note 21, Related Party Transactions, for further discussion.

Debt (Tables)

Debt (Tables)	12 Months Ended
	Dec. 31, 2020
Debt Disclosure [Abstract]
Schedule of Carrying Values Long-Term Debt	The carrying amounts of debt consist of the following (in millions): December 31, 2020 December 31, 2019 Senior Revolver $ 70.0 $ 40.0 Senior Term Loan 484.6 316.9 Unamortized discount and issuance costs (2.6) (2.9) Total debt 552.0 354.0 Less: Current maturities (32.3) (16.3) Total long-term debt $ 519.7 $ 337.7
Schedule of Maturities of Long-term Debt	Scheduled maturities of the Company's long-term debt for each of the five years succeeding December 31, 2020 and thereafter are summarized as follows (in millions): Scheduled Maturities 2021 $ 32.3 2022 38.7 2023 45.2 2024 438.4 Total $ 554.6

Share-Based Compensation (Table

Share-Based Compensation (Tables)	12 Months Ended
	Dec. 31, 2020
Share-based Payment Arrangement [Abstract]
Summary of Valuation Assumptions	The following table sets forth the significant assumptions used in the Black-Scholes option pricing model and the Monte Carlo simulations and the calculation of share-based compensation expense during 2020, 2019, and 2018: Year Ended December 31, 2020 2019 2018 Expected dividend yield —% —% —% Risk-free interest rate 0.3% to 1.7% 1.5% to 2.5% 2.3% to 3.0% Expected volatility 43% 40% to 45% 40% to 45% Expected term (in years) 5.5 2.0 to 5.5 2.6 to 6.3
Schedule of Share-based Compensation Expense	Total share-based compensation costs that have been included in the Company’s consolidated statements of operations were as follows (in millions): Year Ended December 31, 2020 2019 2018 Share-Based Compensation Expense Allocation Details: Cost of services $ 9.9 $ 6.1 $ 5.8 Selling, general and administrative 14.1 12.3 12.4 Other 0.1 0.2 0.2 Total share-based compensation expense (1) $ 24.1 $ 18.6 $ 18.4 (1) In addition to the share-based compensation expense recorded above, $0.1 million , $0.2 million, and $0.3 million of share-based compensation expense was capitalized to deferred contract costs for the year ended December 31, 2020 ,
Schedule of Stock Option Activity	The following table sets forth a summary of all option activity under all plans for the years ended December 31, 2020, 2019, and 2018: Shares Weighted- Weighted- Aggregate Outstanding at January 1, 2018 17,742,966 $ 4.70 7.9 $ 23.7 Granted 274,162 6.51 Exercised (1,713,710) 2.54 Canceled/forfeited (2,418,948) 2.60 Outstanding at December 31, 2018 13,884,470 $ 5.36 6.6 $ 49.2 Granted 52,986 10.06 Exercised (2,640,897) 5.20 Canceled/forfeited (612,299) 2.55 Expired (3,920) 12.98 Outstanding at December 31, 2019 10,680,340 $ 5.59 5.5 $ 81.1 Granted 80,425 11.18 Exercised (3,156,154) 6.13 Canceled/forfeited (169,420) 3.32 Expired (1,214,220) 14.62 Outstanding at December 31, 2020 6,220,971 $ 3.68 5.7 $ 126.5 Outstanding, vested and exercisable at December 31, 2018 7,712,264 $ 7.37 5.4 $ 17.7 Outstanding, vested and exercisable at December 31, 2019 7,868,280 $ 6.57 4.9 $ 52.5 Outstanding, vested and exercisable at December 31, 2020 5,230,690 $ 3.73 5.5 $ 106.2
Schedule of Restricted Stock Awards Activity	The following table sets forth a summary of the activity during the years ended December 31, 2019 and 2018: Shares Weighted- Outstanding and unvested at January 1, 2018 2,352,490 $ 3.03 Vested (1,184,687) 3.07 Forfeited (72,259) 3.24 Outstanding and unvested at December 31, 2018 1,095,544 $ 3.02 Vested (1,094,336) 3.02 Forfeited (1,208) 5.38 Outstanding and unvested at December 31, 2019 — $ —
Schedule of Restricted Stock Units and Performance-based Restricted Stock Units Activity	The following table sets forth a summary of all RSU activity during the years ended December 31, 2020, 2019, and 2018: Shares Weighted- Outstanding and unvested at January 1, 2018 1,183,500 $ 2.50 Granted 441,849 7.99 Vested (323,964) 2.48 Forfeited (174,704) 3.49 Outstanding and unvested at December 31, 2018 1,126,681 $ 4.50 Granted 830,668 10.60 Vested (422,770) 4.07 Forfeited (161,223) 7.00 Outstanding and unvested at December 31, 2019 1,373,356 $ 8.03 Granted 1,588,120 10.29 Vested (504,708) 6.74 Forfeited (348,321) 9.09 Outstanding and unvested at December 31, 2020 2,108,447 $ 9.87 A summary of the PBRSU activity during the years ended December 31, 2020, 2019, and 2018 is shown below: Shares Weighted- Outstanding and unvested at January 1, 2018 4,785,900 $ 3.37 Granted 1,472,677 6.12 Vested — — Forfeited (1,648,129) 3.34 Outstanding and unvested at December 31, 2018 4,610,448 $ 4.26 Granted 1,282,797 9.99 Performance factor adjustment 463,408 2.06 Vested (1,390,223) 2.06 Forfeited (846,994) 5.08 Outstanding and unvested at December 31, 2019 4,119,436 $ 6.37 Granted 1,637,581 13.25 Performance factor adjustment 3,879,186 14.72 Vested (6,344,151) 13.11 Forfeited (374,981) 6.66 Outstanding and unvested at December 31, 2020 2,917,071 $ 11.35

Other expenses (Tables)

Other expenses (Tables)	12 Months Ended
	Dec. 31, 2020
Other Income and Expenses [Abstract]
Schedule of Other Expenses	For the year ended December 31, 2020, 2019, and 2018, other expenses consist of the following (in millions): Year Ended December 31, 2020 2019 2018 Severance and related employee benefits $ 6.4 $ 3.6 $ 2.3 Strategic initiatives (1) 29.3 19.8 19.7 Transitioned employees restructuring expense (2) (0.2) 3.0 4.3 Digital Transformation Office (3) — 8.6 3.6 Facility-exit charges (4) 17.5 (0.2) 0.1 Other (5) 14.3 1.4 0.4 Total other expenses $ 67.3 $ 36.2 $ 30.4 (1) Costs related to evaluating, pursuing, and integrating acquisitions, performing portfolio and capital structure analyses, and other inorganic business projects as part of the Company’s growth strategy. Costs include vendor spend, employee time and expenses spent on activities, severance and retention amounts associated with integration activities, and changes to contingent consideration related to acquisitions. For the year ended December 31, 2020, $4.7 million of contingent consideration changes were included. (2) As part of the transition of personnel to the Company under certain operating partner model contracts, the Company has agreed to reimburse, or directly pay the affected employees, for certain severance and retention costs related to certain employees who will not be transitioned to the Company, or whose jobs will be relocated after the employee transitions to the Company. (3) Project costs related to the Company's initial efforts to automate its transactional environment. (4) As part of evaluating our footprint, we have exited certain leased facilities during the year ended December 31, 2020. Costs include asset impairment charges and other costs related to exited leased facilities. (5) For the year ended December 31, 2020, includes $10.9 million of expenses related to the COVID-19 pandemic, inclusive of appreciation bonuses for the Company’s front-line employees, pandemic response mobilization efforts, telemedicine and testing costs for employees, and other costs.

Income Taxes (Tables)

Income Taxes (Tables)	12 Months Ended
	Dec. 31, 2020
Income Tax Disclosure [Abstract]
Schedule of Domestic and Foreign Components of Income (Loss)	The domestic and foreign components of income (loss) before income taxes consist of the following (in millions): Year Ended December 31, 2020 2019 2018 Domestic $ 99.4 $ 5.0 $ (65.5) Foreign 19.0 4.8 8.8 Total income (loss) before income taxes $ 118.4 $ 9.8 $ (56.7)
Schedule of Current and Deferred Income Tax Expense (Benefit)	For the years ended December 31, 2020, 2019, and 2018, the Company’s current and deferred income tax expense (benefit) attributable to income (loss) from operations are as follows (in millions): Current Deferred Total Year Ended December 31, 2018 U.S. Federal $ — $ (10.3) $ (10.3) State & Local 0.9 (2.6) (1.7) Foreign 1.9 (1.3) 0.6 $ 2.8 $ (14.2) $ (11.4) Year Ended December 31, 2019 U.S. Federal $ (0.3) $ (2.2) $ (2.5) State & Local 0.7 (0.9) (0.2) Foreign 2.5 (2.0) 0.5 $ 2.9 $ (5.1) $ (2.2) Year Ended December 31, 2020 U.S. Federal $ 0.2 $ (0.3) $ (0.1) State & Local — 1.0 1.0 Foreign 2.4 (2.0) 0.4 $ 2.6 $ (1.3) $ 1.3
Schedule of Reconciliation of Effective Income Tax Rate	Reconciliation of the difference between the effective tax rate and the statutory U.S. federal income tax rate is as follows: Year Ended December 31, 2020 2019 2018 Federal statutory tax rate 21 % 21 % 21 % Increase in income tax rate resulting from: State and local income taxes, net of federal tax benefits 1 % (2) % 2 % Additional tax on foreign source income 3 % 18 % (3) % Share-based compensation (24) % (71) % 3 % Non-deductible expense 13 % 24 % (3) % Gain on sale (11) % — % — % Other (2) % (12) % — % Effective tax rate 1 % (22) % 20 %
Schedule of Net Deferred Tax Assets	The following table sets forth the Company’s net deferred tax assets as of December 31, 2020 and 2019 (in millions): As of December 31, 2020 2019 Deferred tax assets and liabilities: Net operating loss carryforwards $ 81.6 $ 64.1 Share-based compensation 8.6 12.4 Accrued bonus 1.4 8.3 Advanced billing revenue 6.4 5.9 Alternative minimum tax 5.2 4.0 Interest expense limitation 5.6 10.2 Deferred rent liabilities 21.3 25.6 Deferred FICA liability 6.0 — Other 10.0 4.5 Total gross deferred tax assets 146.1 135.0 Intangible assets (41.7) (37.0) Fixed assets (3.1) (4.4) Contract implementation costs (7.0) (6.2) Deferred rent assets (14.8) (21.3) Less valuation allowances (5.8) (1.9) Net deferred tax assets $ 73.7 $ 64.2

8.00% Series A Convertible Pr_2

8.00% Series A Convertible Preferred Stock (Tables)	12 Months Ended
	Dec. 31, 2020
Temporary Equity Disclosure [Abstract]
Summary of Preferred Stock Activity	The following summarizes the Preferred Stock activity for the year ended December 31, 2020 and 2019 (in millions, except per share data): Preferred Stock Shares Issued and Outstanding Carrying Value Balance at January 1, 2018 227,483 $ 189.3 Dividends paid/accrued dividends 18,750 19.1 Balance at December 31, 2018 246,233 $ 208.4 Dividends paid/accrued dividends 20,296 20.7 Balance at December 31, 2019 266,529 $ 229.1 Dividends paid/accrued dividends 21,968 22.4 Balance at December 31, 2020 288,497 $ 251.5

Earnings (Loss) Per Share (Tabl

Earnings (Loss) Per Share (Tables)	12 Months Ended
	Dec. 31, 2020
Earnings Per Share [Abstract]
Schedule of Basic and Diluted Net Income (Loss) Per Common Share	Basic and diluted net income (loss) per common share are calculated as follows (in millions, except share and per share data): Year Ended December 31, 2020 2019 2018 Basic EPS: Net income (loss) $ 117.1 $ 12.0 $ (45.3) Less dividends on preferred shares (22.4) (20.7) (19.1) Less income allocated to preferred shareholders (47.3) — — Net income (loss) available/(allocated) to common shareholders - basic $ 47.4 $ (8.7) $ (64.4) Diluted EPS: Net income (loss) $ 117.1 $ 12.0 $ (45.3) Less dividends on preferred shares (22.4) (20.7) (19.1) Less income allocated to preferred shareholders (37.7) — — Net income (loss) available/(allocated) to common shareholders - diluted $ 57.0 $ (8.7) $ (64.4) Basic weighted-average common shares 115,729,645 111,505,993 108,175,159 Add: Effect of dilutive equity awards 12,731,424 — — Add: Effect of dilutive warrants 46,112,201 — — Diluted weighted average common shares 174,573,270 111,505,993 108,175,159 Net income (loss) per common share (basic) $ 0.41 $ (0.08) $ (0.60) Net income (loss) per common share (diluted) $ 0.33 $ (0.08) $ (0.60)

Related Party Transactions (Tab

Related Party Transactions (Tables)	12 Months Ended
	Dec. 31, 2020
Related Party Transactions [Abstract]
Schedule of Related Party Transactions	Net services revenue from services provided to Ascension included in the Company’s consolidated statements of operations were (in millions): Year Ended December 31, 2020 2019 2018 $ 809.5 $ 790.4 $ 600.1 Amounts included in the Company's consolidated balance sheets for Ascension, excluding debt, are (in millions): December 31, 2020 December 31, 2019 Accounts receivable, net of $0.1 million and $0.0 million allowance - related party $ 30.9 $ 30.8 Accrued service costs, current $ 9.1 $ 28.9 Refund liabilities, current 0.6 1.0 Deferred revenue (contract liabilities), current 5.6 4.2 Current portion of customer liabilities 15.3 34.1 Deferred revenue (contract liabilities), non-current 16.3 18.6 Non-current portion of customer liabilities 16.3 18.6 Total customer liabilities $ 31.6 $ 52.7

Deferred Contract Costs (Tables

Deferred Contract Costs (Tables)	12 Months Ended
	Dec. 31, 2020
Deferred Costs, Capitalized, Prepaid, and Other Assets Disclosure [Abstract]
Summary of Deferred Contract Costs	The following table summarizes the breakout of deferred contract costs (in millions): December 31, 2020 December 31, 2019 Prepaid expenses and other current assets $ 4.5 $ 4.0 Other assets 19.6 20.8 Total deferred contract costs $ 24.1 $ 24.8

Prepaid Expenses and Other Cu_2

Prepaid Expenses and Other Current Assets (Tables)	12 Months Ended
	Dec. 31, 2020
Deferred Costs, Capitalized, Prepaid, and Other Assets Disclosure [Abstract]
Schedule of Prepaid Expenses and Other Current Assets	Prepaid expenses and other current assets is comprised of the following (in millions): Year Ended December 31, 2020 2019 Acquisition and disposition contingent assets $ 19.5 $ — Prepaid expenses 18.2 16.7 Deferred contract costs 4.5 4.0 Base fee discounts 3.8 2.6 Lease-related receivables — 4.3 Other current assets 13.4 14.0 Ending balance $ 59.4 $ 41.6

Other Assets (Tables)

Other Assets (Tables)	12 Months Ended
	Dec. 31, 2020
Deferred Costs, Capitalized, Prepaid, and Other Assets Disclosure [Abstract]
Schedule of Other Assets	Other assets is comprised of the following (in millions): Year Ended December 31, 2020 2019 Deferred contract costs $ 19.6 $ 20.8 Base fee discounts 18.1 8.2 Acquisition and disposition contingent assets 10.8 — Prepaid expenses 5.9 4.2 Other assets 6.6 1.8 Ending balance $ 61.0 $ 35.0

Accrued Expenses and Other Cu_2

Accrued Expenses and Other Current Liabilities (Tables)	12 Months Ended
	Dec. 31, 2020
Payables and Accruals [Abstract]
Schedule of Accrued Expenses	Other accrued expenses is comprised of the following (in millions): Year Ended December 31, 2020 2019 Accrued expenses $ 33.2 $ 30.0 Acquisition deferred payments 22.0 — Notes payable 1.9 8.0 Other current liabilities 2.6 2.0 Ending balance $ 59.7 $ 40.0

Description of Business - Narra

Description of Business - Narrative (Details) - USD ($) $ in Millions	Oct. 30, 2020	Feb. 16, 2016	Dec. 31, 2020
Business Acquisition [Line Items]
Long term strategic partnership, term		10 years
Disposal Group, Disposed of by Sale, Not Discontinued Operations | EMS Disposition
Business Acquisition [Line Items]
Sale of EMS business, disposition price	$ 140
Sale of EMS business, hold-back amount included in disposition price	$ 5
Sale of EMS business, hold-back amount, settlement period from date of the disposition	1 year
Sale of EMS business, total sale price, net of cost to sell	$ 132.7
Sale of EMS business, goodwill	$ 7.1
Sale of EMS business, gain recognized			$ 55.7

Summary of Significant Accoun_4

Summary of Significant Accounting Policies - Narrative (Details)	12 Months Ended
	Dec. 31, 2020USD ($)paymentsegmentreporting_unit	Dec. 31, 2019USD ($)	Dec. 31, 2018USD ($)
Revenue from External Customer [Line Items]
Number of operating segments | segment	1
Number of reportable segments | segment	1
Base fees, number of monthly payments | payment	3
Number of reporting units | reporting_unit	1
Impairment of goodwill	$ 0	$ 0
Impairment of property, equipment, software, deferred contract costs, or other intangible assets	$ 0	0	$ 0
Operating Lease, Impairment Loss		$ 0
Minimum | End-To-End Services
Revenue from External Customer [Line Items]
Revenue, contract term	2 years
Minimum | PAS and Modular Services
Revenue from External Customer [Line Items]
Revenue, contract term	1 year
Maximum | End-To-End Services
Revenue from External Customer [Line Items]
Revenue, contract term	10 years
Maximum | PAS and Modular Services
Revenue from External Customer [Line Items]
Revenue, contract term	3 years

Summary of Significant Accoun_5

Summary of Significant Accounting Policies - Property, Equipment and Software (Details)	12 Months Ended
	Dec. 31, 2020
Buildings and land | Minimum
Property, Plant and Equipment [Line Items]
Useful lives	30 years
Buildings and land | Maximum
Property, Plant and Equipment [Line Items]
Useful lives	42 years
Computers and other equipment | Minimum
Property, Plant and Equipment [Line Items]
Useful lives	3 years
Computers and other equipment | Maximum
Property, Plant and Equipment [Line Items]
Useful lives	5 years
Leasehold improvements | Maximum
Property, Plant and Equipment [Line Items]
Useful lives	10 years
Office furniture
Property, Plant and Equipment [Line Items]
Useful lives	5 years
Software | Minimum
Property, Plant and Equipment [Line Items]
Useful lives	3 years
Software | Maximum
Property, Plant and Equipment [Line Items]
Useful lives	5 years

Recent Accounting Pronounceme_2

Recent Accounting Pronouncements - Narrative (Details) - USD ($) $ in Millions	Dec. 31, 2020	Jan. 01, 2020	Dec. 31, 2019	Dec. 31, 2018	Dec. 31, 2017
New Accounting Pronouncements or Change in Accounting Principle [Line Items]
Impact to retained earnings upon adoption	$ (87.9)		$ (18.1)	$ (6.3)	$ (33.4)
Retained Earnings
New Accounting Pronouncements or Change in Accounting Principle [Line Items]
Impact to retained earnings upon adoption	$ 161.5		277.8	$ 289.8	$ 244.5
Cumulative Effect, Period of Adoption, Adjustment
New Accounting Pronouncements or Change in Accounting Principle [Line Items]
Additional allowance for credit losses		$ 1.1
Impact to retained earnings upon adoption			0.8
Cumulative Effect, Period of Adoption, Adjustment | Retained Earnings
New Accounting Pronouncements or Change in Accounting Principle [Line Items]
Impact to retained earnings upon adoption		$ 1.1	$ 0.8

Fair Value of Financial Instr_2

Fair Value of Financial Instruments - Narrative (Details) - Fair Value, Measurements, Recurring	Dec. 31, 2020USD ($)
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Financial assets required to be measured at fair value	$ 0
Financial liabilities required to be measured at fair value	$ 0

Acquisitions - Narrative (Detai

Acquisitions - Narrative (Details)	Aug. 03, 2022USD ($)	Aug. 03, 2021USD ($)	Aug. 03, 2020USD ($)payment	Apr. 01, 2020USD ($)	Aug. 03, 2022USD ($)	Dec. 31, 2020USD ($)	Dec. 31, 2019USD ($)	Dec. 31, 2018USD ($)
Business Acquisition [Line Items]
Purchase price, payment						$ 5,000,000	$ 0	$ 0
Goodwill						375,300,000	$ 253,200,000
SCI Acquisition
Business Acquisition [Line Items]
Purchase price				$ 190,000,000
Other non-current liabilities, note payable				5,000,000
Net sales, since acquisition date						20,700,000
Net loss, before income taxes, since acquisition date						6,900,000
Purchase price				196,700,000
Goodwill				125,600,000
SCI Acquisition | Earn-out Provision
Business Acquisition [Line Items]
Earn-out provision, value				4,800,000		9,500,000
Earn-out provision, high-end estimate				10,000,000
Earn-out provision, low-end estimate				$ 0
RevWorks
Business Acquisition [Line Items]
Net sales, since acquisition date						26,800,000
Purchase price			$ 30,000,000
Purchase price, payment			$ 5,000,000
Number of deferred payments | payment			2
Contractual deferred payments			$ 24,300,000
Goodwill			3,600,000
Net loss, before income taxes, since the acquisition date						500,000
RevWorks | Customer relationships
Business Acquisition [Line Items]
Assets acquired			2,800,000
RevWorks | Subsequent Event | Scenario, Forecast
Business Acquisition [Line Items]
Purchase price, payment	$ 12,500,000	$ 12,500,000			$ 25,000,000
RevWorks | Cerner
Business Acquisition [Line Items]
Contingent consideration asset, (up to)			25,000,000
Asset, contingently returnable consideration			22,300,000
RevWorks | Cerner | Prepaid expenses and other current assets
Business Acquisition [Line Items]
Asset, contingently returnable consideration			11,500,000
RevWorks | Cerner | Other Noncurrent Assets
Business Acquisition [Line Items]
Asset, contingently returnable consideration			$ 10,800,000
RevWorks | Acquisition-related Costs
Business Acquisition [Line Items]
Supplemental pro-forma earnings adjustment						$ 6,000,000

Acquisitions - Fair Value of As

Acquisitions - Fair Value of Assets Acquired and Liabilities Assumed (Details) - USD ($) $ in Millions	Apr. 01, 2020	Dec. 31, 2020	Dec. 31, 2019
Allocation of consideration to assets acquired and liabilities assumed:
Goodwill		$ 375.3	$ 253.2
SCI Acquisition
Business Acquisition [Line Items]
Total purchase consideration	$ 196.7
Allocation of consideration to assets acquired and liabilities assumed:
Cash and cash equivalents	2.9
Accounts receivable	2.8
Prepaid expenses and other current assets	1.1
Property, equipment and software	0.3
Operating lease right-of-use assets	1.2
Intangible assets	86.1
Goodwill	125.6
Accounts payable	(0.2)
Current portion of customer liabilities	(4)
Accrued compensation and benefits	(1.6)
Current portion of operating lease liabilities	(0.5)
Other accrued expenses	(0.4)
Non-current portion of operating lease liabilities	(0.7)
Other non-current liabilities	(5)
Deferred income tax liabilities	(10.9)
Net assets acquired	$ 196.7

Acquisitions - Pro Forma Result

Acquisitions - Pro Forma Results (Details) - RevWorks - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Business Acquisition [Line Items]
Net services revenue	$ 1,320.9	$ 1,297.7
Net income (loss)	$ 115.7	$ (1.6)

Accounts Receivable and Allow_3

Accounts Receivable and Allowance for Credit Losses - Narrative (Details) $ in Millions	Jan. 01, 2020USD ($)
Cumulative Effect, Period of Adoption, Adjustment
Accounts, Notes, Loans and Financing Receivable [Line Items]
Initial increase, allowance for credit losses	$ 1.1

Accounts Receivable and Allow_4

Accounts Receivable and Allowance for Credit Losses - Schedule of Allowance for Credit Losses (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Accounts Receivable, Allowance for Credit Loss [Roll Forward]
Beginning balance	$ 2.8	$ 1.1
Cumulative effect of ASC 326 adoption	3.8	1.1
Provision (recoveries)	0.6	3.1
EMS Disposition	(0.6)	0
Write-offs	(0.1)	(1.4)
Ending balance	3.8	2.8
Cumulative Effect, Period of Adoption, Adjustment
Accounts Receivable, Allowance for Credit Loss [Roll Forward]
Beginning balance	1.1
Cumulative effect of ASC 326 adoption	$ 1.1	1.1
Ending balance		$ 1.1

Property, Equipment and Softw_3

Property, Equipment and Software - Schedule of Property, Equipment and Software (Details) - USD ($) $ in Millions	Dec. 31, 2020	Dec. 31, 2019
Property, Plant and Equipment [Line Items]
Property, equipment and software, gross	$ 224.9	$ 218.8
Less accumulated depreciation and amortization	(131.2)	(101.9)
Property, equipment and software, net	93.7	116.9
Buildings and land
Property, Plant and Equipment [Line Items]
Property, equipment and software, gross	4.6	4.6
Computer and other equipment
Property, Plant and Equipment [Line Items]
Property, equipment and software, gross	55	50.7
Leasehold improvements
Property, Plant and Equipment [Line Items]
Property, equipment and software, gross	23.2	31.1
Software
Property, Plant and Equipment [Line Items]
Property, equipment and software, gross	135.7	123
Office furniture
Property, Plant and Equipment [Line Items]
Property, equipment and software, gross	$ 6.4	$ 9.4

Property, Equipment and Softw_4

Property, Equipment and Software - Narrative (Details) - USD ($) $ in Millions	Dec. 31, 2020	Dec. 31, 2019
Located Internationally
Property, Plant and Equipment [Line Items]
Property, equipment and software	$ 17.1	$ 14.8

Property, Equipment and Softw_5

Property, Equipment and Software - Allocation of Depreciation and Amortization Expense between Cost of Services and Selling, General and Administrative Expenses (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Property, Plant and Equipment [Line Items]
Total depreciation and amortization	$ 50.6	$ 41.8	$ 28.2
Cost of services
Property, Plant and Equipment [Line Items]
Total depreciation and amortization	46.6	37.8	23.9
Selling, general and administrative
Property, Plant and Equipment [Line Items]
Total depreciation and amortization	$ 4	$ 4	$ 4.3

Leases - Narrative (Details)

Leases - Narrative (Details) - Maximum	Dec. 31, 2020
Lessee, Lease, Description [Line Items]
Operating lease, term (up to)	13 years
Finance lease, term (up to)	13 years
Operating lease, renewal term (up to)	10 years
Finance lease, renewal term (up to)	10 years

Leases - Schedule of Lease Cost

Leases - Schedule of Lease Costs (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Leases [Abstract]
Operating lease cost	$ 18.2	$ 19.1
Finance lease cost:
Amortization of ROU assets	0.4	0.8
Interest on lease liabilities	0.1	0.1
Sublease income	(2.2)	(2.2)
Total lease cost	$ 16.5	$ 17.8

Leases - Schedule of Supplement

Leases - Schedule of Supplemental Cash Flow Information (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Cash paid for amounts included in the measurement of lease liabilities:
Operating cash flows for operating leases	$ 20.7	$ 18.7
Operating cash flows for finance leases	0.1	0.1
Financing cash flows for finance leases	0.8	0.8	$ 0
ROU assets obtained in exchange for lease obligations:
Operating leases	3.3	17.3
Finance leases	$ 0	$ 0.7

Leases - Schedule of Suppleme_2

Leases - Schedule of Supplemental Balance Sheet Information (Details)	Dec. 31, 2020	Dec. 31, 2019
Weighted average remaining lease term:
Operating leases	7 years	8 years
Finance leases	2 years	2 years
Weighted average incremental borrowing rate:
Operating leases	8.94%	8.84%
Finance leases	6.62%	6.45%

Leases - Schedule of Operating

Leases - Schedule of Operating and Finance Lease Maturity (Details) $ in Millions	Dec. 31, 2020USD ($)
Operating Leases
2021	$ 18.7
2022	16.1
2023	15.3
2024	15
2025	14.8
Thereafter	34
Total	113.9
Less:
Imputed interest	30.7
Present value of lease liabilities	83.2
Finance Leases
2021	0.5
2022	0.1
2023	0
2024	0
2025	0
Thereafter	0
Total	0.6
Less:
Imputed interest	0
Present value of lease liabilities	$ 0.6

Intangible Assets - Components

Intangible Assets - Components of Intangible Assets (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Finite-Lived Intangible Assets [Line Items]
Gross Carrying Value	$ 199.4	$ 187.7
Accumulated Amortization	(28.3)	(23)
Net Book Value	171.1	164.7
Customer relationships
Finite-Lived Intangible Assets [Line Items]
Gross Carrying Value	97.7	160.9
Accumulated Amortization	(14.7)	(15.6)
Net Book Value	83	145.3
Customer relationships | SCI And RevWorks Acquisitions
Finite-Lived Intangible Assets [Line Items]
Gross Carrying Value	$ 5.6
Weighted Average Useful Life	10 years
Technology
Finite-Lived Intangible Assets [Line Items]
Gross Carrying Value	$ 101.7	26.8
Accumulated Amortization	(13.6)	(7.4)
Net Book Value	88.1	$ 19.4
Technology | SCI And RevWorks Acquisitions
Finite-Lived Intangible Assets [Line Items]
Gross Carrying Value	$ 85.3
Weighted Average Useful Life	10 years

Intangible Assets - Narrative (

Intangible Assets - Narrative (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Goodwill and Intangible Assets Disclosure [Abstract]
Intangible asset amortization expense	$ 18.1	$ 13.9

Intangible Assets - Future Amor

Intangible Assets - Future Amortization (Details) - USD ($) $ in Millions	Dec. 31, 2020	Dec. 31, 2019
Finite-Lived Intangible Assets, Amortization Expense, Maturity Schedule [Abstract]
2021	$ 17.3
2022	17.3
2023	17.3
2024	15.5
2025	14.5
Thereafter	89.2
Net Book Value	$ 171.1	$ 164.7

Goodwill - Carrying Amount of G

Goodwill - Carrying Amount of Goodwill (Details) $ in Millions	12 Months Ended
	Dec. 31, 2020USD ($)
Goodwill [Roll Forward]
Beginning Balance	$ 253.2
Acquisitions	129.2
EMS Disposition	(7.1)
Ending Balance	$ 375.3

Goodwill - Narrative (Details)

Goodwill - Narrative (Details) - USD ($)	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Goodwill and Intangible Assets Disclosure [Abstract]
Impairment of goodwill	$ 0	$ 0

Revenue Recognition - Schedule

Revenue Recognition - Schedule of Disaggregated Revenue by Source (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Disaggregation of Revenue [Line Items]
Net services revenue	$ 1,270.8	$ 1,186.1	$ 868.5
Net operating fees
Disaggregation of Revenue [Line Items]
Net services revenue	1,093.8	1,037.4	760.2
Incentive fees
Disaggregation of Revenue [Line Items]
Net services revenue	70.6	56.2	38.3
Other
Disaggregation of Revenue [Line Items]
Net services revenue	$ 106.4	$ 92.5	$ 70

Revenue Recognition - Schedul_2

Revenue Recognition - Schedule of Contract Balances (Details) - USD ($) $ in Millions	Dec. 31, 2020	Dec. 31, 2019
Disaggregation of Revenue [Line Items]
Receivables, including related party	$ 122.2	$ 83.1
Contract assets	0	2
Current customer liabilities, related party	12.3	6.7
Non-current customer liabilities, related party	16.3	18.6
Contract With Customer Liability
Disaggregation of Revenue [Line Items]
Contract liabilities	28.6	25.3
Investor
Disaggregation of Revenue [Line Items]
Current customer liabilities, related party	$ 5.6	$ 4.2

Revenue Recognition - Narrative

Revenue Recognition - Narrative (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Disaggregation of Revenue [Line Items]
Revenue recognized	$ 91.6	$ 69.7
Revenue performance obligation, period	PAS performance obligations are typically short in duration (often less than 1 day) with any uncertainty related to the associated variable consideration resolved as each increment of service (completion of a level of care review or an appeal) is completed which reflects the value the customer receives from the Company’s fulfillment of the performance obligation.
Accounts Receivable
Disaggregation of Revenue [Line Items]
Revenue recognized, advanced billings		$ 85	$ 66.7

Revenue Recognition - Transacti

Revenue Recognition - Transaction Price Allocated to the Remaining Performance Obligation (Details) $ in Millions	Dec. 31, 2020USD ($)
Net operating fees
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations	$ 281.4
Incentive fees
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations	21.7
Other
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations	$ 23.7
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2021-01-01
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations, period	1 year
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2021-01-01 | Net operating fees
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations	$ 112.6
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2021-01-01 | Incentive fees
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations	4.1
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2021-01-01 | Other
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations	$ 3.7
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2022-01-01
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations, period	1 year
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2022-01-01 | Net operating fees
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations	$ 62.3
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2022-01-01 | Incentive fees
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations	17.6
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2022-01-01 | Other
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations	$ 5.7
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2023-01-01
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations, period	1 year
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2023-01-01 | Net operating fees
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations	$ 48
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2023-01-01 | Incentive fees
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations	0
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2023-01-01 | Other
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations	$ 5.7
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2024-01-01
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations, period	1 year
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2024-01-01 | Net operating fees
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations	$ 27.5
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2024-01-01 | Incentive fees
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations	0
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2024-01-01 | Other
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations	$ 5.7
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2025-01-01
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations, period	1 year
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2025-01-01 | Net operating fees
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations	$ 18.3
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2025-01-01 | Incentive fees
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations	0
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2025-01-01 | Other
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations	$ 2.9
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2026-01-01
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations, period
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2026-01-01 | Net operating fees
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations	$ 12.7
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2026-01-01 | Incentive fees
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations	0
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2026-01-01 | Other
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction [Line Items]
Revenue expected to be recognized in the future related to unsatisfied performance obligations	$ 0

Customer Liabilities - Schedule

Customer Liabilities - Schedule of Customer Liabilities (Details) - USD ($) $ in Millions	Dec. 31, 2020	Dec. 31, 2019
Other Liabilities Disclosure [Abstract]
Accrued service costs, current	$ 12.2	$ 33.3
Collections payable to clients, current	4.6	5.4
Customer deposits, current	0	1.7
Refund liabilities, current	2.9	1
Deferred revenue (contract liabilities), current	12.3	6.7
Current portion of customer liabilities	32	48.1
Deferred revenue (contract liabilities), non-current	16.3	18.6
Non-current portion of customer liabilities	16.3	18.6
Total customer liabilities	$ 48.3	$ 66.7

Debt - Carrying Amounts of Debt

Debt - Carrying Amounts of Debt (Details) - USD ($) $ in Millions	Dec. 31, 2020	Dec. 31, 2019
Debt Instrument [Line Items]
Long-term debt	$ 554.6
Unamortized discount and issuance costs	(2.6)	$ (2.9)
Total debt	552	354
Less: Current maturities	(32.3)	(16.3)
Total long-term debt	519.7	337.7
Senior Revolver | Line of Credit
Debt Instrument [Line Items]
Long-term debt	70	40
Senior Term Loan | Line of Credit
Debt Instrument [Line Items]
Long-term debt	$ 484.6	$ 316.9

Debt - Narrative (Details)

Debt - Narrative (Details) - USD ($)	Jan. 19, 2021	Jan. 15, 2021	Jun. 26, 2019	Feb. 16, 2016	Jun. 30, 2019	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018	Jan. 13, 2021	Mar. 20, 2020
Debt Instrument [Line Items]
Loss on debt extinguishment					$ 18,800,000	$ 0	$ 18,800,000	$ 0
Long-term debt						$ 554,600,000
Redeemable Convertible Preferred Stock
Debt Instrument [Line Items]
Preferred stock, dividend rate						8.00%	8.00%
TCP-ASC ACHI Series LLLP | Redeemable Convertible Preferred Stock
Debt Instrument [Line Items]
Preferred stock, dividend rate				8.00%		8.00%
Subsequent Event | TCP-ASC ACHI Series LLLP
Debt Instrument [Line Items]
Cash paid, stock conversion		$ 105,000,000
Subsequent Event | TCP-ASC ACHI Series LLLP | Redeemable Convertible Preferred Stock
Debt Instrument [Line Items]
Preferred stock, dividend rate	8.00%	8.00%
Disposal Group, Disposed of by Sale, Not Discontinued Operations | EMS Disposition | Subsequent Event
Debt Instrument [Line Items]
Net proceeds from disposition, obligation waived									$ 135,000,000
Line of Credit
Debt Instrument [Line Items]
Interest rate						2.40%
Mandatory prepayments, percentage of annual excess cash flow			50.00%
Mandatory prepayments, percentage of non-ordinary course asset sales or other dispositions			100.00%
Mandatory prepayments, percentage of net cash proceeds of debt incurrence			100.00%
Line of Credit | Prepayment Period through June 30, 2021
Debt Instrument [Line Items]
Periodic principal installments			$ 6,500,000
Line of Credit | Prepayment Period through June 30, 2023
Debt Instrument [Line Items]
Periodic principal installments			9,700,000
Line of Credit | Prepayment Period through March 31, 2024
Debt Instrument [Line Items]
Periodic principal installments			$ 12,900,000
Line of Credit | Minimum
Debt Instrument [Line Items]
Commitment fee			0.30%
Line of Credit | Maximum
Debt Instrument [Line Items]
Commitment fee			0.50%
Line of Credit | Federal Funds Rate
Debt Instrument [Line Items]
Basis spread on variable rate basis			0.50%
Line of Credit | Eurodollar Rate
Debt Instrument [Line Items]
Variable rate basis, minimum (not less than)			0.00%
Line of Credit | Eurodollar Rate | Interest Rate Option - Basis Spread One
Debt Instrument [Line Items]
Basis spread on variable rate basis			1.00%
Line of Credit | Eurodollar Rate | Interest Rate Option - Basis Spread One | Minimum
Debt Instrument [Line Items]
Basis spread on variable rate basis			0.75%
Line of Credit | Eurodollar Rate | Interest Rate Option - Basis Spread One | Maximum
Debt Instrument [Line Items]
Basis spread on variable rate basis			1.75%
Line of Credit | Eurodollar Rate | Interest Rate Option Two
Debt Instrument [Line Items]
Variable rate basis, minimum (not less than)			0.00%
Line of Credit | Eurodollar Rate | Interest Rate Option Two | Minimum
Debt Instrument [Line Items]
Basis spread on variable rate basis			1.75%
Line of Credit | Eurodollar Rate | Interest Rate Option Two | Maximum
Debt Instrument [Line Items]
Basis spread on variable rate basis			2.75%
Senior Term Loan | Line of Credit
Debt Instrument [Line Items]
Credit agreement, maximum borrowing capacity			$ 325,000,000
Credit agreement, issuance percentage of par			99.66%
Debt maturity			5 years
Long-term debt						$ 484,600,000	$ 316,900,000
Senior Revolver | Line of Credit
Debt Instrument [Line Items]
Principle of debt issued			$ 100,000,000
Debt maturity			5 years
Long-term debt						70,000,000	$ 40,000,000
Line of Credit | Line of Credit
Debt Instrument [Line Items]
Long-term debt						70,000,000
Borrowing availability						30,000,000
Letter of Credit | Line of Credit
Debt Instrument [Line Items]
Long-term debt						$ 0
Incremental Term Loan | Line of Credit
Debt Instrument [Line Items]
Additional borrowing capacity										$ 191,100,000
Incremental Term Loan | Line of Credit | Subsequent Event
Debt Instrument [Line Items]
Line of credit, reduction to availability of funds for certain investments, debt prepayments or restricted payments									$ 105,000,000

Debt - Schedule of Maturities o

Debt - Schedule of Maturities of Long-term Debt (Details) $ in Millions	Dec. 31, 2020USD ($)
Debt Disclosure [Abstract]
2021	$ 32.3
2022	38.7
2023	45.2
2024	438.4
Total	$ 554.6

Stockholders' Equity (Deficit)

Stockholders' Equity (Deficit) - Narrative (Details)	Feb. 16, 2016USD ($)$ / sharesshares	Dec. 31, 2020USD ($)vote$ / sharesshares	Dec. 31, 2019USD ($)$ / sharesshares	Dec. 31, 2018shares	Jan. 23, 2018$ / sharesshares	Dec. 31, 2017shares	Nov. 13, 2013USD ($)
Class of Stock [Line Items]
Preferred stock, shares authorized (in shares)		5,000,000	5,000,000
Preferred stock, par or stated value per share (in dollars per share) | $ / shares		$ 0.01	$ 0.01
Common stock, par value (in dollars per share) | $ / shares		$ 0.01	$ 0.01
Common stock, vote per share | vote		1
Dividends declared or paid on common stock | $		$ 0	$ 0
Stock repurchase program, authorized amount | $							$ 50,000,000
Stock repurchased during period, shares (in shares)		0	0
Treasury stock, shares retired (in shares)		0
Treasury stock, shares (in shares)		5,321,393	5,321,393
Restricted Stock Awards and Restricted Stock Units
Class of Stock [Line Items]
Shares paid for tax withholding for share-based compensation (in shares)		2,882,255	973,303
Redeemable Convertible Preferred Stock
Class of Stock [Line Items]
Preferred stock, shares issued (in shares)		288,497	266,529
Preferred stock, dividend rate		8.00%	8.00%
Preferred stock, par value (in dollars per share) | $ / shares		$ 0.01	$ 0.01
Temporary equity, shares outstanding (in shares)		288,497	266,529	246,233		227,483
TCP-ASC ACHI Series LLLP
Class of Stock [Line Items]
Warrant exercise price (in dollars per share) | $ / shares	$ 3.50
TCP-ASC ACHI Series LLLP | Redeemable Convertible Preferred Stock
Class of Stock [Line Items]
Preferred stock, shares issued (in shares)	200,000
Preferred stock, dividend rate	8.00%	8.00%
Preferred stock, par value (in dollars per share) | $ / shares	$ 0.01
Preferred stock, issued, value | $	$ 200,000,000
Long-term purchase commitment, period	10 years
TCP-ASC ACHI Series LLLP | Redeemable Convertible Preferred Stock | Ascension
Class of Stock [Line Items]
Preferred stock, dividend rate		8.00%
TCP-ASC ACHI Series LLLP | Common Stock
Class of Stock [Line Items]
Number of securities called by warrants (in shares) (up to)	60,000,000
Warrant exercise price (in dollars per share) | $ / shares	$ 3.50
Long-term purchase commitment, period	10 years
Intermountain | Common Stock
Class of Stock [Line Items]
Number of securities called by warrants (in shares) (up to)					1,500,000
Warrant exercise price (in dollars per share) | $ / shares					$ 6

Share-Based Compensation - Narr

Share-Based Compensation - Narrative (Details) $ / shares in Units, $ in Millions	1 Months Ended	12 Months Ended
	Dec. 31, 2016shares	Dec. 31, 2020USD ($)plan$ / sharesshares	Dec. 31, 2019USD ($)$ / sharesshares	Dec. 31, 2018USD ($)$ / sharesshares
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Number of stock incentive plans | plan		2
Maximum number of shares issuable under plan (in shares) (up to)		46,374,756
Income tax benefit, vesting and exercises of equity awards | $		$ 37.3	$ 8.2	$ 2.4
Weighted-average grant date fair value of options granted (in dollars per share) | $ / shares		$ 4.41	$ 4.25	$ 3.01
Total intrinsic value of options exercised | $		$ 30.5	$ 16.4	$ 9.6
Total fair value of options vested | $		2.2	3.4	4.2
Shares paid for tax withholding for share-based compensation, cost | $		$ 65.6	$ 11	3
Treasury stock due to canceled RSA (in shares)		5,321,393	5,321,393
Minimum
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Award vesting period		1 year
Maximum
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Award vesting period		4 years
Employee Stock Option
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Award expiration period		10 years
Restricted Stock Awards
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Fair value of restricted stock vested in period | $			$ 3.3	$ 3.6
Shares paid for tax withholding for share-based compensation (in shares)			380,564	404,466
Shares paid for tax withholding for share-based compensation, cost | $			$ 3.8	$ 2.3
Treasury stock due to canceled RSA (in shares)			1,208	72,259
Granted (in shares)		0
Restricted Stock Units (RSUs)
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Shares paid for tax withholding for share-based compensation (in shares)		141,331	109,112	94,603
Shares paid for tax withholding for share-based compensation, cost | $		$ 1.4	$ 1.1	$ 0.7
Granted (in shares)		1,588,120	830,668	441,849
Performance-Based Restricted Stock Units (PBRSUs)
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Shares paid for tax withholding for share-based compensation (in shares)		2,740,924	483,627
Shares paid for tax withholding for share-based compensation, cost | $		$ 64.2	$ 6.1
Maximum number of shares that could vest (in shares)		5,363,408
Granted (in shares)		1,637,581	1,282,797	1,472,677
Performance-Based Restricted Stock Units (PBRSUs) | Minimum
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Number of shares vesting if market-based conditions met, potential percentage of the number originally granted		0.00%
Number of shares vesting if price targets met, potential percentage of the number originally granted		0.00%
Performance-Based Restricted Stock Units (PBRSUs) | Maximum
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Number of shares vesting if market-based conditions met, potential percentage of the number originally granted		150.00%
Number of shares vesting if price targets met, potential percentage of the number originally granted		200.00%
Amended and Restated 2010 Stock Incentive Plan
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Number of additional shares authorized (in shares)	17,000,000
Stock Incentive Plan 2010
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Available for future grant (in shares)		5,028,242

Share-Based Compensation - Assu

Share-Based Compensation - Assumptions (Details)	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Expected dividend yield	0.00%	0.00%	0.00%
Risk-free interest rate, minimum	0.30%	1.50%	2.30%
Risk-free interest rate, maximum	1.70%	2.50%	3.00%
Expected volatility	43.00%
Expected volatility, minimum		40.00%	40.00%
Expected volatility, maximum		45.00%	45.00%
Expected term (in years)	5 years 6 months
Minimum
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Expected term (in years)		2 years	2 years 7 months 6 days
Maximum
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Expected term (in years)		5 years 6 months	6 years 3 months 18 days

Share-Based Compensation - Comp

Share-Based Compensation - Compensation Expense Allocation (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Total share-based compensation expense	$ 24.1	$ 18.6	$ 18.4
Share-based compensation expense capitalized to deferred contract costs	0.1	0.2	0.3
Cost of services
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Total share-based compensation expense	9.9	6.1	5.8
Selling, general and administrative
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Total share-based compensation expense	14.1	12.3	12.4
Other
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Total share-based compensation expense	$ 0.1	$ 0.2	$ 0.2

Share-Based Compensation - Stoc

Share-Based Compensation - Stock Option Activity (Details) - USD ($) $ / shares in Units, $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018	Dec. 31, 2017
Shares
Outstanding at beginning of period (in shares)	10,680,340	13,884,470	17,742,966
Granted (in shares)	80,425	52,986	274,162
Exercised (in shares)	(3,156,154)	(2,640,897)	(1,713,710)
Canceled/forfeited (in shares)	(169,420)	(612,299)	(2,418,948)
Expired (in shares)	(1,214,220)	(3,920)
Outstanding at end of period (in shares)	6,220,971	10,680,340	13,884,470	17,742,966
Outstanding, vested and exercisable at end of period (in shares)	5,230,690	7,868,280	7,712,264
Weighted- Average Exercise Price
Outstanding at beginning of period (in dollars per share)	$ 5.59	$ 5.36	$ 4.70
Granted (in dollars per share)	11.18	10.06	6.51
Exercised (in dollars per share)	6.13	5.20	2.54
Canceled/forfeited (in dollars per share)	3.32	2.55	2.60
Expired (in dollars per share)	14.62	12.98
Outstanding at end of period (in dollars per share)	3.68	5.59	5.36	$ 4.70
Outstanding, vested and exercisable at end of period (in dollars per share)	$ 3.73	$ 6.57	$ 7.37
Weighted- Average Remaining Contractual Term (in years)
Outstanding at end of period	5 years 8 months 12 days	5 years 6 months	6 years 7 months 6 days	7 years 10 months 24 days
Outstanding, vested and exercisable at end of period	5 years 6 months	4 years 10 months 24 days	5 years 4 months 24 days
Aggregate Intrinsic Value (in millions)
Outstanding at end of period	$ 126.5	$ 81.1	$ 49.2	$ 23.7
Outstanding, vested and exercisable at end of period	$ 106.2	$ 52.5	$ 17.7

Share-Based Compensation - Rest

Share-Based Compensation - Restricted Stock Award Activity (Details) - Restricted Stock Awards - $ / shares	12 Months Ended
	Dec. 31, 2019	Dec. 31, 2018
Shares
Outstanding and unvested at beginning of period (in shares)	1,095,544	2,352,490
Vested (in shares)	(1,094,336)	(1,184,687)
Forfeited (in shares)	(1,208)	(72,259)
Outstanding and unvested at end of period (in shares)	0	1,095,544
Weighted- Average Grant Date Fair Value
Outstanding and unvested at beginning of period (in dollars per share)	$ 3.02	$ 3.03
Vested (in dollars per share)	3.02	3.07
Forfeited (in dollars per share)	5.38	3.24
Outstanding and unvested at end of period (in dollars per share)	$ 0	$ 3.02

Share-Based Compensation - Re_2

Share-Based Compensation - Restricted Stock Unit and Performance-Based Restricted Stock Unit Activity (Details) - $ / shares	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Restricted Stock Units (RSUs)
Shares
Outstanding and unvested at beginning of period (in shares)	1,373,356	1,126,681	1,183,500
Granted (in shares)	1,588,120	830,668	441,849
Vested (in shares)	(504,708)	(422,770)	(323,964)
Forfeited (in shares)	(348,321)	(161,223)	(174,704)
Outstanding and unvested at end of period (in shares)	2,108,447	1,373,356	1,126,681
Weighted- Average Grant Date Fair Value
Outstanding and unvested at beginning of period (in dollars per share)	$ 8.03	$ 4.50	$ 2.50
Granted (in dollars per share)	10.29	10.60	7.99
Vested (in dollars per share)	6.74	4.07	2.48
Forfeited (in dollars per share)	9.09	7	3.49
Outstanding and unvested at end of period (in dollars per share)	$ 9.87	$ 8.03	$ 4.50
Performance-Based Restricted Stock Units (PBRSUs)
Shares
Outstanding and unvested at beginning of period (in shares)	4,119,436	4,610,448	4,785,900
Granted (in shares)	1,637,581	1,282,797	1,472,677
Performance factor adjustment (in shares)	3,879,186	463,408
Vested (in shares)	(6,344,151)	(1,390,223)	0
Forfeited (in shares)	(374,981)	(846,994)	(1,648,129)
Outstanding and unvested at end of period (in shares)	2,917,071	4,119,436	4,610,448
Weighted- Average Grant Date Fair Value
Outstanding and unvested at beginning of period (in dollars per share)	$ 6.37	$ 4.26	$ 3.37
Granted (in dollars per share)	13.25	9.99	6.12
Performance factor adjustment (in dollars per share)	14.72	2.06
Vested (in dollars per share)	13.11	2.06	0
Forfeited (in dollars per share)	6.66	5.08	3.34
Outstanding and unvested at end of period (in dollars per share)	$ 11.35	$ 6.37	$ 4.26

Other expenses - Other Costs (D

Other expenses - Other Costs (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Other Income and Expenses [Abstract]
Severance and related employee benefits	$ 6.4	$ 3.6	$ 2.3
Strategic initiatives	29.3	19.8	19.7
Transitioned employees restructuring expense	(0.2)	3	4.3
Digital Transformation Office	0	8.6	3.6
Facility-exit charges	17.5	(0.2)	0.1
Other	14.3	1.4	0.4
Total other expenses	67.3	$ 36.2	$ 30.4
Contingent consideration changes included in strategic initiatives	4.7
COVID-19 related costs, included in Other	$ 10.9

Income Taxes - Schedule of Dome

Income Taxes - Schedule of Domestic and Foreign Components of Income (Loss) (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Income Tax Disclosure [Abstract]
Domestic	$ 99.4	$ 5	$ (65.5)
Foreign	19	4.8	8.8
Income (loss) before income tax provision (benefit)	$ 118.4	$ 9.8	$ (56.7)

Income Taxes - Schedule of Curr

Income Taxes - Schedule of Current and Deferred Income Tax Expense (Benefit) (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Current
U.S. Federal	$ 0.2	$ (0.3)	$ 0
State & Local	0	0.7	0.9
Foreign	2.4	2.5	1.9
Current Income Tax Expense (Benefit)	2.6	2.9	2.8
Deferred
U.S. Federal	(0.3)	(2.2)	(10.3)
State & Local	1	(0.9)	(2.6)
Foreign	(2)	(2)	(1.3)
Deferred Income Tax Expense (Benefit)	(1.3)	(5.1)	(14.2)
Total
U.S. Federal	(0.1)	(2.5)	(10.3)
State & Local	1	(0.2)	(1.7)
Foreign	0.4	0.5	0.6
Total Current and Deferred Income Tax Expense (Benefit)	$ 1.3	$ (2.2)	$ (11.4)

Income Taxes - Schedule of Effe

Income Taxes - Schedule of Effective Income Tax Rate Reconciliation (Details)	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Income Tax Disclosure [Abstract]
Federal statutory tax rate	21.00%	21.00%	21.00%
Increase in income tax rate resulting from:
State and local income taxes, net of federal tax benefits	1.00%	(2.00%)	2.00%
Additional tax on foreign source income	3.00%	18.00%	(3.00%)
Share-based compensation	(24.00%)	(71.00%)	3.00%
Non-deductible expense	13.00%	24.00%	(3.00%)
Gain on sale	(11.00%)	0.00%	0.00%
Other	(2.00%)	(12.00%)	0.00%
Effective tax rate	1.00%	(22.00%)	20.00%

Income Taxes - Schedule of Net

Income Taxes - Schedule of Net Deferred Tax Assets (Details) - USD ($) $ in Millions	Dec. 31, 2020	Dec. 31, 2019
Deferred tax assets and liabilities:
Net operating loss carryforwards	$ 81.6	$ 64.1
Share-based compensation	8.6	12.4
Accrued bonus	1.4	8.3
Advanced billing revenue	6.4	5.9
Alternative minimum tax	5.2	4
Interest expense limitation	5.6	10.2
Deferred rent liabilities	21.3	25.6
Deferred FICA liability	6	0
Other	10	4.5
Total gross deferred tax assets	146.1	135
Intangible assets	(41.7)	(37)
Fixed assets	(3.1)	(4.4)
Contract implementation costs	(7)	(6.2)
Deferred rent assets	(14.8)	(21.3)
Less valuation allowances	(5.8)	(1.9)
Net deferred tax assets	$ 73.7	$ 64.2

Income Taxes - Narrative (Detai

Income Taxes - Narrative (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Income Tax Examination [Line Items]
Valuation allowance	$ 5.8	$ 1.9
Current tax provision	2.6	2.9	$ 2.8
Unrecognized tax benefits	$ 0	0	0
Statute of limitations minimum	3 years
Statute of limitations maximum	6 years
SCI Acquisition | Deferred Tax Assets, Tax Credit Carryforwards, Research
Income Tax Examination [Line Items]
Valuation allowance	$ 3.7
U.S. Federal
Income Tax Examination [Line Items]
Operating loss carryforwards	320.6
State
Income Tax Examination [Line Items]
Operating loss carryforwards	282
Valuation allowance	5.8	1.9
India
Income Tax Examination [Line Items]
Current tax provision	2.4	1.9	1.5
Benefit from tax holiday	$ 4.3	$ 2.2	$ 1.6

8.00% Series A Convertible Pr_3

8.00% Series A Convertible Preferred Stock - Narrative (Details) - USD ($)	Jan. 19, 2021	Jan. 15, 2021	Feb. 16, 2016	Jan. 31, 2020	Jan. 31, 2019	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Temporary Equity [Line Items]
Accrued dividends						$ 5,800,000	$ 5,300,000	$ 4,900,000
Dividends paid in cash				$ 940	$ 580
TCP-ASC ACHI Series LLLP
Temporary Equity [Line Items]
Warrant exercise price (in dollars per share)			$ 3.50
TCP-ASC ACHI Series LLLP | Subsequent Event
Temporary Equity [Line Items]
Cash paid, stock conversion		$ 105,000,000
Redeemable Convertible Preferred Stock
Temporary Equity [Line Items]
Preferred stock, shares issued (in shares)						288,497	266,529
Preferred stock, dividend rate						8.00%	8.00%
Liquidation preference per share (in dollars per share)						$ 1,000
Accrued dividends						$ 5,800,000	$ 5,300,000
Dividends paid in additional shares of Preferred Stock						5,800,000	5,300,000
Dividends paid or accrued						$ 22,400,000	$ 20,700,000
Redeemable Convertible Preferred Stock | TCP-ASC ACHI Series LLLP
Temporary Equity [Line Items]
Preferred stock, shares issued (in shares)			200,000
Preferred stock, issued, value			$ 200,000,000
Long-term purchase commitment, period			10 years
Preferred stock, dividend rate			8.00%			8.00%
Redeemable Convertible Preferred Stock | TCP-ASC ACHI Series LLLP | Subsequent Event
Temporary Equity [Line Items]
Number of shares converted (in shares)		294,266
Preferred stock, dividend rate	8.00%	8.00%
Common Stock | TCP-ASC ACHI Series LLLP
Temporary Equity [Line Items]
Long-term purchase commitment, period			10 years
Number of securities called by warrants (in shares) (up to)			60,000,000
Warrant exercise price (in dollars per share)			$ 3.50
Common Stock | TCP-ASC ACHI Series LLLP | Subsequent Event
Temporary Equity [Line Items]
Number of shares issued in stock conversion (in shares)		117,706,400
Additional shares issued (in shares)		21,582,800

8.00% Series A Convertible Pr_4

8.00% Series A Convertible Preferred Stock - Schedule of Preferred Stock Activity (Details) - Redeemable Convertible Preferred Stock - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Shares Issued and Outstanding
Beginning Balance (in shares)	266,529	246,233	227,483
Dividends paid/accrued dividends (in shares)	21,968	20,296	18,750
Ending Balance (in shares)	288,497	266,529	246,233
Carrying Value
Beginning Balance	$ 229.1	$ 208.4	$ 189.3
Dividends paid/accrued dividends	22.4	20.7	19.1
Ending Balance	$ 251.5	$ 229.1	$ 208.4

Earnings (Loss) Per Share - Com

Earnings (Loss) Per Share - Computation of Basic Diluted Earnings Per Share (Details) - USD ($) $ / shares in Units, $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Basic EPS:
Net income (loss)	$ 117.1	$ 12	$ (45.3)
Less dividends on preferred shares	(22.4)	(20.7)	(19.1)
Less income allocated to preferred shareholders	(47.3)	0	0
Net income (loss) available/(allocated) to common shareholders - basic	47.4	(8.7)	(64.4)
Diluted EPS:
Less income allocated to preferred shareholders	(37.7)	0	0
Net income (loss) available/(allocated) to common shareholders - diluted	$ 57	$ (8.7)	$ (64.4)
Basic weighted-average common shares (in shares)	115,729,645	111,505,993	108,175,159
Add: Effect of dilutive equity awards (in shares)	12,731,424	0	0
Add: Effect of dilutive warrants (in shares)	46,112,201	0	0
Diluted weighted average common shares (in shares)	174,573,270	111,505,993	108,175,159
Net income (loss) per common share (basic) (in dollars per share)	$ 0.41	$ (0.08)	$ (0.60)
Net income (loss) per common share (diluted) (in dollars per share)	$ 0.33	$ (0.08)	$ (0.60)

Earnings (Loss) Per Share - Nar

Earnings (Loss) Per Share - Narrative (Details) - shares	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Antidilutive Securities Excluded from Computation of Earnings Per Share [Line Items]
Antidilutive securities excluded from computation of earnings per share (in shares)	97,244	21,262,959	25,725,761
Warrant | Investor's
Antidilutive Securities Excluded from Computation of Earnings Per Share [Line Items]
Antidilutive securities excluded from computation of earnings per share (in shares)		61,500,000

Related Party Transactions - Na

Related Party Transactions - Narrative (Details) - USD ($) $ in Millions	Jun. 26, 2019	Feb. 16, 2016	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Related Party Transaction [Line Items]
Interest expense, related party				$ 7.2	$ 9.5
Redeemable Convertible Preferred Stock
Related Party Transaction [Line Items]
Preferred stock, dividend rate, percentage			8.00%	8.00%
Redeemable Convertible Preferred Stock | TCP-ASC ACHI Series LLLP
Related Party Transaction [Line Items]
Preferred stock, dividend rate, percentage		8.00%	8.00%
Ascension | Redeemable Convertible Preferred Stock | TCP-ASC ACHI Series LLLP
Related Party Transaction [Line Items]
Preferred stock, dividend rate, percentage			8.00%
Related Party
Related Party Transaction [Line Items]
Repayment of subordinated notes, prepayment penalty amount	$ 2.2

Related Party Transactions - Ne

Related Party Transactions - Net Services Revenue (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Related Party Transactions [Abstract]
Net services revenue, Ascension	$ 809.5	$ 790.4	$ 600.1

Related Party Transactions - Su

Related Party Transactions - Summary Amounts Included in Balance Sheet (Details) - USD ($) $ in Millions	Dec. 31, 2020	Dec. 31, 2019
Related Party Transaction [Line Items]
Accounts receivable, net of $0.1 million and $0.0 million allowance - related party	$ 30.9	$ 30.8
Refund liabilities, current	2.9	1
Deferred revenue (contract liabilities), current	12.3	6.7
Current portion of customer liabilities	32	48.1
Deferred revenue (contract liabilities), non-current	16.3	18.6
Non-current portion of customer liabilities	16.3	18.6
Total customer liabilities	48.3	66.7
Ascension
Related Party Transaction [Line Items]
Accounts receivable, net of $0.1 million and $0.0 million allowance - related party	30.9	30.8
Accrued service costs, current	9.1	28.9
Refund liabilities, current	0.6	1
Deferred revenue (contract liabilities), current	5.6	4.2
Current portion of customer liabilities	15.3	34.1
Non-current portion of customer liabilities	16.3	18.6
Total customer liabilities	$ 31.6	$ 52.7

Deferred Contract Costs - Summa

Deferred Contract Costs - Summary of Deferred Contract Costs (Details) - USD ($) $ in Millions	Dec. 31, 2020	Dec. 31, 2019
Capitalized Contract Cost [Line Items]
Total deferred contract costs	$ 24.1	$ 24.8
Prepaid expenses and other current assets
Capitalized Contract Cost [Line Items]
Total deferred contract costs	4.5	4
Other assets
Capitalized Contract Cost [Line Items]
Total deferred contract costs	$ 19.6	$ 20.8

Deferred Contract Costs - Narra

Deferred Contract Costs - Narrative (Details) - USD ($)	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Deferred Costs, Capitalized, Prepaid, and Other Assets Disclosure [Abstract]
Contract amortization	$ 4,800,000	$ 3,300,000
Impairment losses	$ 0	$ 0

Segments and Customer Concent_2

Segments and Customer Concentrations - Narrative (Details) - segment	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Segment Reporting Information [Line Items]
Number of operating segments	1
Number of reportable segments	1
Sales Revenue | Customer Concentration Risk | Ascension
Segment Reporting Information [Line Items]
Concentration percentage	64.00%	67.00%	69.00%
Sales Revenue | Customer Concentration Risk | Intermountain Healthcare
Segment Reporting Information [Line Items]
Concentration percentage	14.00%	15.00%	14.00%
Accounts Receivable | Customer Concentration Risk | Ascension
Segment Reporting Information [Line Items]
Concentration percentage	25.00%	37.00%

Derivative Financial Instrume_2

Derivative Financial Instruments - Narrative (Details) - Designated as Hedging Instrument - Cash Flow Hedging - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Foreign Currency Forward Contracts
Derivative [Line Items]
Gain (loss) reported in accumulated other comprehensive income	$ 0.4
Gain (loss) to be reclassified within next 12 months	0.4
Derivatives, net gain (loss) reclassified into cost of services	0.8	$ (1.3)
Notional amount	55.9	52.6
Interest Rate Swap
Derivative [Line Items]
Gain (loss) reported in accumulated other comprehensive income	(2.3)
Gain (loss) to be reclassified within next 12 months	(1.4)
Derivatives, net gain (loss) reclassified into cost of services	1.4	(0.2)
Notional amount	$ 200	$ 100

Retirement Plan - Narrative (De

Retirement Plan - Narrative (Details) - USD ($)	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Defined Benefit Plan Disclosure [Line Items]
Maximum employee contributions to the plan, per annum	$ 19,500	$ 19,000	$ 18,500
Company match to 401(k) contributions made by employee, percent	50.00%
Base compensation that a participant contributes to the plan the company currently matches	6.00%
Company contributions to the plan	$ 2,900,000	6,600,000	5,200,000
Intermedix
Defined Benefit Plan Disclosure [Line Items]
Company match to 401(k) contributions made by employee, percent	100.00%
Base compensation that a participant contributes to the plan the company currently matches	1.00%
Company contributions to the plan	$ 700,000	$ 1,700,000	$ 1,100,000
Company match to 401(k) contributions made by employee, proceeding initial plan percentage criteria, percent	50.00%
Base compensation that a participant contributes to the plan, proceeding initial percentage criteria, the company currently matches	5.00%

Prepaid Expenses and Other Cu_3

Prepaid Expenses and Other Current Assets - Schedule of Prepaid Expenses and Other Current Assets (Details) - USD ($) $ in Millions	Dec. 31, 2020	Dec. 31, 2019
Deferred Costs, Capitalized, Prepaid, and Other Assets Disclosure [Abstract]
Acquisition and disposition contingent assets	$ 19.5	$ 0
Prepaid expenses	18.2	16.7
Deferred contract costs	4.5	4
Base fee discounts	3.8	2.6
Lease-related receivables	0	4.3
Other current assets	13.4	14
Ending balance	$ 59.4	$ 41.6

Other Assets - Schedule of Othe

Other Assets - Schedule of Other Assets (Details) - USD ($) $ in Millions	Dec. 31, 2020	Dec. 31, 2019
Deferred Costs, Capitalized, Prepaid, and Other Assets Disclosure [Abstract]
Deferred contract costs	$ 19.6	$ 20.8
Base fee discounts	18.1	8.2
Acquisition and disposition contingent assets	10.8	0
Prepaid expenses	5.9	4.2
Other assets	6.6	1.8
Ending balance	$ 61	$ 35

Accrued Expenses and Other Cu_3

Accrued Expenses and Other Current Liabilities - Schedule of Accrued Compensation and Benefits (Details) - USD ($) $ in Millions	Dec. 31, 2020	Dec. 31, 2019
Payables and Accruals [Abstract]
Accrued expenses	$ 33.2	$ 30
Acquisition deferred payments	22	0
Notes payable	1.9	8
Other current liabilities	2.6	2
Other accrued expenses	$ 59.7	$ 40

Subsequent Event - Narrative (D

Subsequent Event - Narrative (Details) - Redeemable Convertible Preferred Stock	Jan. 19, 2021	Jan. 15, 2021	Feb. 16, 2016	Dec. 31, 2020	Dec. 31, 2019
Subsequent Event [Line Items]
Preferred stock, dividend rate				8.00%	8.00%
TCP-ASC ACHI Series LLLP
Subsequent Event [Line Items]
Preferred stock, dividend rate			8.00%	8.00%
TCP-ASC ACHI Series LLLP | Subsequent Event
Subsequent Event [Line Items]
Preferred stock, dividend rate	8.00%	8.00%

Uncategorized Items - ah-202012

Label	Element	Value
Accounting Standards Update [Extensible List]	us-gaap_AccountingStandardsUpdateExtensibleList	us-gaap:AccountingStandardsUpdate201613Member