R1 RCM (RCM) 10-K 16 Feb 23 2022 FY Annual report Financial data

Cover Page

Cover Page - USD ($)	12 Months Ended
	Dec. 31, 2022	Feb. 14, 2023	Jun. 30, 2022
Cover [Abstract]
Document Type	10-K
Document Annual Report	true
Document Period End Date	Dec. 31, 2022
Current Fiscal Year End Date	--12-31
Document Transition Report	false
Entity File Number	001-41428
Entity Registrant Name	R1 RCM Inc. /DE
Entity Incorporation, State or Country Code	DE
Entity Tax Identification Number	87-4340782
Entity Address, Address Line One	434 W. Ascension Way
Entity Address, Address Line Two	6th Floor
Entity Address, City or Town	Murray
Entity Address, State or Province	UT
Entity Address, Postal Zip Code	84123
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			$ 2,950,791,223
Entity Common Stock, Shares Outstanding (in shares)		416,661,713
Documents Incorporated by Reference	Portions of the registrant’s definitive proxy statement for its 2023 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	2022
Document Fiscal Period Focus	FY
Entity Central Index Key	0001910851

Audit Information

Audit Information	12 Months Ended
	Dec. 31, 2022
Audit Information [Abstract]
Auditor Firm ID	42
Auditor Name	Ernst & Young LLP
Auditor Location	Chicago, Illinois

Consolidated Balance Sheets

Consolidated Balance Sheets - USD ($) $ in Millions	Dec. 31, 2022	Dec. 31, 2021
Current assets:
Cash and cash equivalents	$ 110.1	$ 130.1
Accounts receivable, net of $15.1 million and $2.4 million allowance as of December 31, 2022 and 2021, respectively	235.2	131.3
Accounts receivable, net of $0.1 million and $0.1 million allowance - related party as of December 31, 2022 and 2021, respectively	25	26.1
Current portion of contract assets, net	83.9	0
Prepaid expenses and other current assets	110.3	77.2
Total current assets	564.5	364.7
Property, equipment and software, net	164.8	94.7
Operating lease right-of-use assets	80.5	48.9
Non-current portion of contract assets, net	32	0
Non-current portion of deferred contract costs	26.7	23.4
Intangible assets, net	1,514.5	265.4
Goodwill	2,658.2	554.7
Non-current deferred tax assets	10.4	51.8
Other assets	88.2	45.7
Total assets	5,139.8	1,449.3
Current liabilities:
Accounts payable	33.4	17.7
Current portion of customer liabilities	57.5	41.5
Current portion of customer liabilities - related party	7.4	7.9
Accrued compensation and benefits	109	97
Current portion of operating lease liabilities	18	13.5
Current portion of long-term debt	53.9	17.5
Accrued expenses and other current liabilities	70.6	59.1
Total current liabilities	349.8	254.2
Non-current portion of customer liabilities	5	3.3
Non-current portion of customer liabilities - related party	13.7	15.4
Non-current portion of operating lease liabilities	94.4	53.4
Long-term debt	1,732.6	754.9
Non-current deferred tax liabilities	200.7	4.2
Other non-current liabilities	23.1	17.2
Total liabilities	2,419.3	1,102.6
Stockholders’ equity:
Common stock, $0.01 par value, 750,000,000 shares authorized, 439,950,125 shares issued and 416,597,885 shares outstanding at December 31, 2022; 500,000,000 shares authorized, 298,320,928 shares issued and 278,226,242 shares outstanding at December 31, 2021	4.4	3
Additional paid-in capital	3,123.2	628.5
Accumulated deficit	(121.9)	(64.3)
Accumulated other comprehensive loss	(3.4)	(5.3)
Treasury stock, at cost, 23,352,240 shares as of December 31, 2022; 20,094,686 shares as of December 31, 2021	(281.8)	(215.2)
Total stockholders’ equity	2,720.5	346.7
Total liabilities and stockholders’ equity	$ 5,139.8	$ 1,449.3

Consolidated Balance Sheets (Pa

Consolidated Balance Sheets (Parenthetical) - USD ($) $ in Millions	Dec. 31, 2022	Dec. 31, 2021
Accounts receivable, allowance	$ 15.1	$ 2.4
Common stock, par value (in dollars per share)	$ 0.01	$ 0.01
Common stock, shares authorized (in shares)	750,000,000	500,000,000
Common stock, shares issued (in shares)	439,950,125	298,320,928
Common stock, shares outstanding (in shares)	416,597,885	278,226,242
Treasury stock, shares (in shares)	23,352,240	20,094,686
Related Party
Accounts receivable, allowance	$ 0.1	$ 0.1

Consolidated Statements of Oper

Consolidated Statements of Operations and Comprehensive Income (Loss) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2022	Dec. 31, 2021	Dec. 31, 2020
Income Statement [Abstract]
Net services revenue ($881.0 million, $893.5 million and $809.5 million from related party for the years ended December 31, 2022, 2021, and 2020, respectively)	$ 1,806.4	$ 1,474.6	$ 1,270.8
Operating expenses:
Cost of services	1,445.1	1,162.8	1,021.1
Selling, general and administrative	174.8	120	102.4
Other expenses	183.5	46.1	67.3
Total operating expenses	1,803.4	1,328.9	1,190.8
Income from operations	3	145.7	80
Gain on business disposition	0	0	55.7
Net interest expense	(64)	(18.9)	(17.3)
Income (loss) before income tax provision (benefit)	(61)	126.8	118.4
Income tax provision (benefit)	(3.4)	29.6	1.3
Net income (loss)	$ (57.6)	$ 97.2	$ 117.1
Net income (loss) per common share:
Basic (in dollars per share)	$ (0.16)	$ (1.86)	$ 0.41
Diluted (in dollars per share)	$ (0.16)	$ (1.86)	$ 0.33
Weighted average shares used in calculating net income (loss) per common share:
Basic (in shares)	352,337,767	266,183,565	115,729,645
Diluted (in shares)	352,337,767	266,183,565	174,573,270
Consolidated statements of comprehensive income (loss)
Net income (loss)	$ (57.6)	$ 97.2	$ 117.1
Other comprehensive income (loss):
Net change on derivatives designated as cash flow hedges, net of tax	9.2	2.1	(1.7)
Foreign currency translation adjustment	(7.3)	(0.9)	(0.3)
Total other comprehensive income (loss), net of tax	1.9	1.2	(2)
Comprehensive income (loss)	(55.7)	98.4	115.1
Basic:
Net income (loss)	(57.6)	97.2	117.1
Less dividends on preferred shares	0	(592.3)	(22.4)
Less income allocated to preferred shareholders	0	0	(47.3)
Net income (loss) available/allocated to common shareholders - basic	(57.6)	(495.1)	47.4
Diluted:
Net income (loss)	(57.6)	97.2	117.1
Less dividends on preferred shares	0	(592.3)	(22.4)
Less income allocated to preferred shareholders	0	0	(37.7)
Net income (loss) available/allocated to common shareholders - diluted	$ (57.6)	$ (495.1)	$ 57

Consolidated Statements of Op_2

Consolidated Statements of Operations and Comprehensive Income (Loss) (Parenthetical) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2022	Dec. 31, 2021	Dec. 31, 2020
Income Statement [Abstract]
Net services revenue, from related party	$ 881	$ 893.5	$ 809.5

Consolidated Statements of Stoc

Consolidated Statements of Stockholders' Equity - USD ($) $ in Millions	Total	CoyCo 2	Cumulative Effect, Period of Adoption, Adjustment	Cumulative Effect, Period of Adoption, Adjusted Balance	Common Stock	Common Stock Cumulative Effect, Period of Adoption, Adjusted Balance	Treasury Stock	Treasury Stock Cumulative Effect, Period of Adoption, Adjusted Balance	Additional Paid-In Capital	Additional Paid-In Capital CoyCo 2	Additional Paid-In Capital Cumulative Effect, Period of Adoption, Adjusted Balance	Accumulated Deficit	Accumulated Deficit Cumulative Effect, Period of Adoption, Adjustment	Accumulated Deficit Cumulative 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, 2019					127,807,546	127,807,546
Beginning Balance (in shares) at Dec. 31, 2019							(13,786,266)	(13,786,266)
Beginning 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				$ 0				19.3
Dividends paid/accrued on preferred stock	(22.4)								(22.4)
Acquisition of treasury stock related to share-based compensation plans (in shares)							(2,882,255)
Acquisition of treasury stock related to share-based compensation 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 income (loss)	117.1											117.1
Ending Balance (in shares) at Dec. 31, 2020					137,812,559
Ending Balance (in shares) at Dec. 31, 2020							(16,668,521)
Ending Balance at Dec. 31, 2020	87.9				$ 1.4		$ (139.2)		393.7			(161.5)			(6.5)
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Share-based compensation expense	74.9								74.9
Issuance of common stock related to share-based compensation plans (in shares)					2,325,918
Issuance of common stock related to share-based compensation plans	0				$ 0				0
Issuance of common stock (in shares)					324,212
Issuance of common stock	$ 7								7
Exercise of vested stock options (in shares)	1,819,039				1,819,039
Exercise of vested stock options	$ 8								8
Acquisition of treasury stock related to share-based compensation plans (in shares)							(796,908)
Acquisition of treasury stock related to share-based compensation plans	(19.1)						$ (19.1)
Repurchases of common stock (in shares)							(2,629,257)
Repurchases of common stock	(56.9)						$ (56.9)
Net change on derivatives designated as cash flow hedges, net of tax	2.1														2.1
Foreign currency translation adjustment	(0.9)														(0.9)
Conversion of preferred shares (in shares)					117,706,400
Conversion of preferred shares	251.5				$ 1.2				250.3
Inducement dividend	(592.3)								(592.3)
Issuance of common stock related to inducement (in shares)					21,582,800
Issuance of common stock related to inducement	487.3				$ 0.2				487.1
Exercise of warrants pursuant to cashless provisions (in shares)					16,750,000
Exercise of warrants pursuant to cashless provisions	0				$ 0.2				(0.2)
Net income (loss)	$ 97.2											97.2
Ending Balance (in shares) at Dec. 31, 2021	298,320,928				298,320,928
Ending Balance (in shares) at Dec. 31, 2021	(20,094,686)						(20,094,686)
Ending Balance at Dec. 31, 2021	$ 346.7				$ 3		$ (215.2)		628.5			(64.3)			(5.3)
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Share-based compensation expense	62.3	$ 5.1							62.3	$ 5.1
Issuance of common stock related to share-based compensation plans (in shares)					2,954,694
Issuance of common stock (in shares)					137,389,275
Issuance of common stock	2,412.8				$ 1.4				2,411.4
Replacement awards issued in conjunction with acquisitions	$ 11.3								11.3
Exercise of vested stock options (in shares)	1,285,228				1,285,228		2,282
Exercise of vested stock options	$ 4.5						$ (0.1)		4.6
Acquisition of treasury stock related to share-based compensation plans (in shares)							(1,174,754)
Acquisition of treasury stock related to share-based compensation plans	(27.6)						$ (27.6)
Repurchases of common stock (in shares)							(2,080,518)
Repurchases of common stock	(38.9)						$ (38.9)
Net change on derivatives designated as cash flow hedges, net of tax	9.2														9.2
Foreign currency translation adjustment	(7.3)														(7.3)
Net income (loss)	$ (57.6)											(57.6)
Ending Balance (in shares) at Dec. 31, 2022	439,950,125				439,950,125
Ending Balance (in shares) at Dec. 31, 2022	(23,352,240)						(23,352,240)
Ending Balance at Dec. 31, 2022	$ 2,720.5				$ 4.4		$ (281.8)		$ 3,123.2			$ (121.9)			$ (3.4)

Consolidated Statements of St_2

Consolidated Statements of Stockholders' Equity (Parenthetical) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2022	Dec. 31, 2021	Dec. 31, 2020	Dec. 31, 2019
Accounting Standards Update [Extensible List]				ASC 326
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	$ 3.1	$ 0.7	$ 0.6

Consolidated Statements of Cash

Consolidated Statements of Cash Flows - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2022	Dec. 31, 2021	Dec. 31, 2020
Operating activities
Net income (loss)	$ (57.6)	$ 97.2	$ 117.1
Adjustments to reconcile net income (loss) to net cash (used in) provided by operations:
Depreciation and amortization	172	77.5	68.7
Amortization of debt issuance costs	3.6	1.2	1
Share-based compensation	62	74.3	24.1
CoyCo 2 share-based compensation	5.1	0	0
Gain on sale of Emergency Medical Services business	0	0	(55.7)
Loss/(gain) on disposal and right-of-use asset write-downs	21.1	(0.4)	17
Provision for credit losses	11.8	0.7	0.6
Deferred income taxes	(6.8)	23	(1.2)
Non-cash lease expense	14	9.7	7.3
Other	6.5	(1.9)	4.7
Changes in operating assets and liabilities:
Accounts receivable and related party accounts receivable	(51.8)	(33.2)	(56.5)
Contract assets	(24.1)	0	0
Prepaid expenses and other assets	(39.4)	(18)	(12.9)
Accounts payable	(16)	0.1	(3.4)
Accrued compensation and benefits	(77.7)	42	(40.3)
Lease liabilities	(18.9)	(12.7)	(13.6)
Other liabilities	(1.5)	(13.3)	25.3
Customer liabilities and customer liabilities - related party	(12.2)	18.6	(20.4)
Net cash (used in) provided by operating activities	(9.9)	264.8	61.8
Investing activities
Purchases of property, equipment, and software	(93.5)	(51.7)	(49.3)
Payment for business acquisitions, net of cash acquired	(847.7)	(294.7)	(196)
Proceeds from sale of Emergency Medical Services business, net of cash disposed	0	0	128.3
Other	(8.3)	6	0
Net cash used in investing activities	(949.5)	(340.4)	(117)
Financing activities
Payment of debt issuance costs	(1)	(1.9)	0
Payment of contingent consideration liability	0	(4.8)	0
Deferred payment related to acquisition of RevWorks	0	(12.5)	0
Inducement of preferred stock conversion	0	(105)	0
Payment of equity issuance costs	(2)	0	0
Exercise of vested stock options	4.6	8.9	18.4
Purchase of treasury stock	(39.3)	(56.5)	0
Shares withheld for taxes	(30.2)	(16.3)	(71.9)
Other	(0.2)	(0.2)	(5.8)
Net cash provided by financing activities	943	31.4	137.9
Effect of exchange rate changes in cash	(3.6)	(0.5)	(0.4)
Net (decrease) increase in cash, cash equivalents, and restricted cash	(20)	(44.7)	82.3
Cash, cash equivalents, and restricted cash at beginning of period	130.1	174.8	92.5
Cash, cash equivalents, and restricted cash at end of period	110.1	130.1	174.8
Supplemental disclosures of cash flow information
Accrued dividends payable to preferred stockholders	0	0	5.8
Property, equipment and software purchases not paid	26.9	19.5	11
Assets obtained in exchange for common stock	24.3	7	0
Interest paid	61	17.3	15.8
Income taxes paid	8.6	5.2	4.2
Income taxes refunded	0	0.2	0.4
Term A Loans
Financing activities
Issuance of senior secured debt, net of discount and issuance costs and borrowings on revolver	1,016.6	698.6	190.6
Repayment of senior secured debt and revolver	(25.5)	(488.9)	(23.4)
Senior Revolver
Financing activities
Issuance of senior secured debt, net of discount and issuance costs and borrowings on revolver	50	120	50
Repayment of senior secured debt and revolver	$ (30)	$ (110)	$ (20)

Description of Business

Description of Business	12 Months Ended
	Dec. 31, 2022
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 patient registration, insurance and benefit verification, scheduling, 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 domain experience, innovative technology and intelligent automation, 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 largest 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’s employees are the revenue cycle personnel providing services and the Company typically controls third party vendors either through direct contracts or the assumption of the customer’s vendor contracts. As a result, under the operating partner model the Company records higher expenses as well as higher revenues related to the negotiated cost to collect. Under the co-managed model, the revenue cycle personnel and third party vendors remain with the customer and those costs do not impact the Company’s financial results. For the years ended December 31, 2022, 2021, and 2020, 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 solutions, allowing customers to engage the Company to address specific revenue cycle improvement opportunities, such as revenue intelligence solutions (which were enhanced through the acquisition of Revint Holdings, LLC (“Cloudmed”)), automation solutions, revenue integrity solutions, PM, accounts receivables and denials recovery, PAS, CDI, coding management, business office services, and patient experience. 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 “2016 Transaction”). As part of the 2016 Transaction, the Company amended and restated its Master Professional Services Agreement (“A&R MPSA”) with Ascension Health (“Ascension”) effective February 16, 2016 with an initial 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. On April 30, 2021, the Company and Ascension entered into Amendment No. 5 to the A&R MPSA, effective as of May 1, 2021, extending the agreement to April 30, 2031, among other amendments. Cloudmed Acquisition On June 21, 2022, pursuant to the Transaction Agreement and Plan of Merger (the “Transaction Agreement”), dated as of January 9, 2022, among R1 RCM Inc. (f/k/a Project Roadrunner Parent Inc.), R1 RCM Holdco Inc. (f/k/a R1 RCM Inc.), now a wholly-owned subsidiary of the Company (“Old R1 RCM”), Project Roadrunner Merger Sub Inc., formerly a wholly-owned subsidiary of the Company (“R1 Merger Sub”), Cloudmed, CoyCo 1, L.P. (“CoyCo 1”), CoyCo 2, L.P. (“CoyCo 2” and, together with CoyCo 1, the “Sellers”), and, solely for certain purposes set forth therein, NMC Ranger Holdings, LLC, the Company purchased Cloudmed, a leader in Revenue Intelligence™ solutions for healthcare providers, and affiliated entities (collectively, the “Cloudmed entities”), through (i) a merger of R1 Merger Sub with and into Old R1 RCM with Old R1 RCM as the surviving entity, which resulted in Old R1 RCM becoming a wholly-owned subsidiary of the Company (the “Holding Company Reorganization”) and (ii) the Sellers contributing 100% of the equity of a blocker parent corporation of the Cloudmed entities in exchange for an aggregate of 135,929,742 shares of common stock, of the Company subject to certain adjustments following the closing as set forth in the Transaction Agreement (the “Cloudmed Acquisition,” and together with the Holding Company Reorganization, the “2022 Transactions”). In October 2022, the Company finalized those adjustments, resulting in an additional 55,846 shares issued to the Sellers. For further details on the total consideration paid, refer to Note 3, Acquisitions. Cloudmed’s revenue intelligence platform combines cloud-based data architecture and deep domain expertise with intelligent automation to analyze large volumes of medical records, payment data, and complex medical insurance models to identify opportunities to deliver additional revenue to customers. The Company believes this transaction will enable the Company to further its ability to deliver transformative value to healthcare providers through a more fulsome platform of differentiated capabilities by creating a scaled leader across both end-to-end RCM and technology-driven revenue intelligence. Holding Company Reorganization Pursuant to the Transaction Agreement, immediately prior to the completion of the Cloudmed Acquisition, Old R1 RCM implemented the Holding Company Reorganization, which resulted in the Company owning all of the capital stock of Old R1 RCM. Each share of Old R1 RCM’s common stock that was issued and outstanding immediately prior to the Holding Company Reorganization was automatically exchanged into an equivalent corresponding share of Company Common Stock, having the same designations, rights, powers, and preferences and the qualifications, limitations, and restrictions as the corresponding share of common stock of Old R1 RCM being converted. Accordingly, upon consummation of the Holding Company Reorganization, all Old R1 RCM stockholders became stockholders of the Company. Immediately prior to the consummation of the Holding Company Reorganization, the name of Old R1 RCM was changed to “R1 RCM Holdco Inc.” and the name of the Company was changed to “R1 RCM Inc.” The Company is the successor issuer to Old R1 RCM pursuant to Rule 12g-3(a) under the Securities Exchange Act of 1934, as amended (the “Exchange Act”). The shares of Company Common Stock, as successor to Old R1 RCM, began trading on The Nasdaq Global Select Market (“Nasdaq”) under the symbol “RCM” on June 22, 2022. Emergency Medical Services Disposition

Summary of Significant Accounti

Summary of Significant Accounting Policies	12 Months Ended
	Dec. 31, 2022
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. Revenue Recognition The Company’s largest source of revenue is its operating partner arrangement to provide end-to-end RCM services. The Company also generates revenue through modular RCM solutions, where customers will engage the Company for only specific components of its end-to-end RCM service offering on a fixed-fee or volumetric basis. Revenue Cycle Management RCM services fees are primarily variable and performance related, and are generally viewed as a series of distinct services in which there are identifiable increments within a long-term service contract. 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 modular 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. Modular and Other The Company recognizes revenue related to modular and other RCM fees as RCM services are provided. Fees are typically variable in nature and revenue is recognized as services are provided or when any uncertainty associated with the variable fee is subsequently resolved. 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 upon request. 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 solutions 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 three 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. Revenue for the individual services is recognized ratably as services are performed, which is materially within the same accounting period for the services in the bundle. 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 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, rent, share-based compensation, amortization of intangible assets, assumed vendor contracts for onboarded customers, and other costs. Costs associated with generating the Company’s net services revenue are expensed as incurred, with the exception of deferred contract costs, which are certain costs associated with the initial phases of customer contracts and the related transition of customer hospitals and physician groups that are deferred. These fulfillment costs relate directly to the Company’s responsibilities under the corresponding customer contracts, generate or enhance resources of the Company that will be used in satisfying its performance obligations in the future, and are expected to be recovered through the margins realized. The following table summarizes the breakout of deferred contract costs: December 31, 2022 December 31, 2021 Prepaid expenses and other current assets $ 5.1 $ 3.7 Non-current portion of deferred contract costs 26.7 23.4 Total deferred contract costs $ 31.8 $ 27.1 The associated assets are amortized as services are transferred to the customer over the remaining life of the contracts. For the years ended December 31, 2022 and 2021, total amortization was $8.3 million and $4.6 million, respectively, and there were no associated impairment losses. Comprehensive Income Comprehensive income is the net income of the Company combined with other changes in stockholders’ equity 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. Cloud Computing Arrangements The Company capitalizes qualifying set-up and implementation costs related to the Company’s cloud computing arrangements. The deferred costs are amortized over the term of the associated cloud computing arrangement on a straight-line basis unless another systematic and rational basis is more representative of the pattern in which the Company expects to benefit from access to the cloud computing arrangement. Capitalized cloud computing implementation costs are presented in prepaid expenses and other current assets and other assets on the Consolidated Balance Sheets. As of December 31, 2022 and 2021, the Company had net capitalized cloud computing implementation costs of $6.8 million and $8.6 million, respectively. 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. 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 years and indefinite Computers and other equipment 3 years Leasehold improvements Shorter of 10 years or lease term Office furniture 5 years Software 3 to 5 years Property, equipment and software consist of the following: December 31, 2022 December 31, 2021 Buildings and land $ 24.3 $ — Computer and other equipment 75.6 60.4 Leasehold improvements 24.1 23.3 Software 243.2 177.0 Office furniture 12.4 6.5 Property, equipment and software, gross 379.6 267.2 Less accumulated depreciation and amortization (214.8) (172.5) Property, equipment and software, net $ 164.8 $ 94.7 Property, equipment and software, net, located internationally was $20.3 million and $13.9 million as of December 31, 2022 and 2021, 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: Year Ended December 31, 2022 2021 2020 Cost of services $ 53.4 $ 51.8 $ 46.6 Selling, general and administrative 1.2 2.8 4.0 Total depreciation and amortization $ 54.6 $ 54.6 $ 50.6 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, 2022, 2021, and 2020. For the years ended December 31, 2022, 2021, and 2020, we impaired ROU assets and related leasehold improvements related to leased facilities which we exited. See Note 8, Leases, and Note 14, Other, for more information. 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. Fair Value of Financial Instruments The 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, 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 and liabilities such as cash and cash equivalents, restricted cash equivalents, accounts receivable, net, accounts payable, accrued service costs, accrued compensation and benefits, and certain other current assets and accrued expenses, approximate their fair values, due to their short-term nature. See Note 11, 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 loans (see Note 10, Debt) approximates fair value as they are variable rate bank debt. Other than the items discussed above, the Company does not have any financial assets or liabilities that are required to be measured at fair value on a recurring basis. 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. 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. As of December 31, 2022 and 2021, the Company had net assets of $81.5 million and $51.0 million in foreign entities, respectively. 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. For the year ended December 31, 2022, the number of options granted (24,344) was immaterial. As part of the transactions contemplated by the Transaction Agreement, equity awards held by certain employees of Cloudmed (“Former Class P Units”) were modified, through a series of transactions, into awards (“Management Units”) of CoyCo 2. Certain Former Class P Units that were subject to performance-based vesting conditions did not become vested upon the closing of the Cloudmed Acquisition (“Unvested Units”). The Management Units issued by CoyCo 2 are treated as share-based compensation under ASC 718, Compensation - Stock Compensation. The Unvested Units are not awards of the Company and the participants will receive no additional shares of the Company upon satisfaction of the vesting criteria described in Note 13, Share-Based Compensation. However, GAAP requires the Company recognize the cost of share-based compensation granted by an investor (CoyCo 2) to the Company’s employees and service providers for services that benefit the Company’s operations (hereafter, “CoyCo 2 share-based compensation expense”), and a corresponding capital contribution because the costs are incurred on the Company’s behalf. A Monte Carlo simulation was used to estimate the fair value of the Unvested Units. 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. 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 formerly but no longer in issue (as defined in Note 12) participates in dividends alongside the Company’s common stock (per their participating dividends), the preferred stock would constitute participating securities under ASC 260-10, Earnings Per Share, 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 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, restricted stock units (“RSUs”), performance-based restricted stock units (“PBRSUs”), and shares issuable upon conversion of preferred stock. Recently Issued Accounting Standards and Disclosures In October 2021, the Financial Accounting Standards Board (“FASB”) issued Accounting Standards Update (“ASU”) 2021-08, Business Combinations (Topic 805): Accounting for Contract Assets and Contract Liabilities from Contracts with Customers (“ASU 2021-08”). ASU 2021-08 requires companies to apply Topic 606, Revenue from Contracts with Customers, to recognize and measure contract assets and contract liabilities obtained in a business combination. The ASU amendments will generally result in the recognition of contract assets and contract liabilities by the acquirer at amounts consistent with those recorded by the acquiree immediately before the acquisition date. The Company prospectively adopted ASU 2021-08 effective April 1, 2022 and preliminarily recognized contract assets of $92.4 million and contract liabilities of $3.3 million as part of the Cloudmed Acquisition. In June 2022, the FASB issued ASU 2022-03, Fair Value Measurement (Topic 820): Fair Value Measurement of Equity Securities Subject to Contractual Sale Restrictions (“ASU 2022-03”). ASU 2022-03 clarifies that a contractual sale restriction on an equity security should not be considered in measuring the security’s fair value. The Company will adopt ASU 2022-03 prospectively effective January 1, 2024 and is currently evaluating the impact of the standard on its consolidated financial statements.

Acquisitions

Acquisitions	12 Months Ended
	Dec. 31, 2022
Business Combination and Asset Acquisition [Abstract]
Acquisitions	Acquisitions Assets acquired and liabilities assumed in a business combination are recorded at their estimated fair value on the date of the acquisition. The difference between the purchase price amount and the net fair value of assets acquired and liabilities assumed is recognized as goodwill on the balance sheet if the purchase price exceeds the estimated net fair value or as a bargain purchase gain on the income statement if the purchase price is less than the estimated net fair value. The allocation of the purchase price may be modified up to one year after the acquisition date as more information is obtained about the fair value of assets acquired and liabilities assumed. Cloudmed On June 21, 2022, the Company completed the acquisition of Cloudmed for a purchase price of $3.3 billion. The following table summarizes the fair value of the total consideration paid: Fair Value Stock consideration transferred to the Sellers (1) $ 2,390.5 Cash consideration (2) 879.8 Replacement awards issued to Cloudmed equity award holders (3) 11.3 Total consideration $ 3,281.6 (1) The stock consideration fair value includes a 12.5% discount for lack of marketability factor related to an 18-month lock-up period during which the Sellers may not sell their Company common stock. (2) Cash consideration includes the repayment of Cloudmed’s pre-existing credit facility that was paid off at closing and was not assumed by the Company. (3) Represents the pre-acquisition service portion of the fair value of 1,536,220 replacement RSUs issued to Cloudmed equity award holders at closing. The Company funded the cash consideration component and the Company’s associated transaction expenses with a combination of cash on hand and the incurrence of additional indebtedness (see Note 10, Debt). The purchase price has been provisionally allocated to assets acquired and liabilities assumed based on their fair value as of the acquisition date. The fair value estimate of assets acquired and liabilities assumed is pending the completion of various elements, including gathering further information about the identification and completeness of all assets and liabilities acquired, the finalization of an independent appraisal and valuation of the fair value of the assets acquired and liabilities assumed, and final review by the Company’s management. Some of the more significant amounts that are not yet finalized relate to the fair value of intangible assets (including goodwill), contract assets, and income and non-income related taxes. Accordingly, management considers the balances shown in the following table to be preliminary, and there could be adjustments to the consolidated financial statements, including changes in our amortization expense related to the valuation of intangible assets acquired and their respective useful lives, among other adjustments. The preliminary fair value of assets acquired and liabilities assumed is: Purchase Price Allocation Total purchase consideration $ 3,281.6 Allocation of consideration to assets acquired and liabilities assumed: Cash and cash equivalents $ 32.1 Accounts receivable 61.8 Current portion of contract assets 68.5 Property, equipment and software 5.0 Operating lease right-of-use assets 25.3 Non-current portion of contract assets 23.9 Intangible assets 1,366.6 Goodwill 2,103.6 Other assets 6.7 Accounts payable (31.9) Customer liabilities (3.3) Accrued compensation and benefits (93.0) Operating lease liabilities (25.4) Deferred income tax liabilities (245.4) Other liabilities (12.9) Net assets acquired $ 3,281.6 The intangible assets identified in conjunction with the Cloudmed Acquisition and their preliminary fair values are as follows: Useful Life Gross Carrying Value Customer Relationships 18 years $ 318.0 Technology 7 years $ 1,025.0 Tradename 5 years $ 23.5 Favorable leasehold interests Life of lease $ 0.1 The goodwill recognized is primarily attributable to growth and cost reduction synergies that are expected to be achieved from the integration of Cloudmed. None of the goodwill is expected to be deductible for income tax purposes. Included in the Consolidated Statements of Operations and Comprehensive Income (Loss) for the year ended December 31, 2022 are net sales of $260.0 million and net loss before income taxes of $10.7 million related to the operations of Cloudmed since the acquisition date of June 21, 2022. Measurement period adjustments The Company had various measurement period adjustments due to an updated valuation report and additional information received since the Cloudmed Acquisition. The significant adjustments during the three months ended December 31, 2022 included a $3.5 million decrease to intangible assets related to updated assumptions and information included in the valuation report, an increase to the deferred income tax liability of $103.4 million related to updated tax return information, and an offset of these changes to goodwill. In conjunction with the adjustments, the Company adjusted amortization expense in the three months ended December 31, 2022. Prior Acquisitions During 2021, the Company acquired the following business: Company Name Description of the Business Description of the Acquisition iVinci Partners, LLC d/b/a VisitPay (“VisitPay”) Provider of digital payment solutions Purchased all outstanding equity interests In 2020, the Company purchased certain assets related to the RevWorks services business from Cerner Corporation. In accordance with the purchase agreement, the Company paid the first deferred payment of $12.5 million in the third quarter of 2021. The remaining deferred payment of $12.5 million was payable on the second anniversary of the closing date (August 2022) and is included in other accrued expenses on the Consolidated Balance Sheet as of December 31, 2022 as it had not been paid as of such date. The two deferred payments related to the RevWorks acquisition were contractual obligations of the Company; however, they are refundable to the Company if certain RevWorks customer revenue targets defined in the purchase agreement for the first two years following the acquisition are not achieved. The parties are currently engaged in arbitration to finalize the remaining deferred payment and contingently refundable consideration amounts. The contingently refundable consideration is stated at an amount approximating the amount expected to be realized. Pro Forma Results (Unaudited) The following table summarizes, on a pro forma basis, the combined results of the Company as though the Cloudmed Acquisition had occurred as of January 1, 2021 and the VisitPay acquisition had occurred as of January 1, 2020. These pro forma results are not necessarily indicative of the actual consolidated results had the acquisitions occurred as of those dates or of the future consolidated operating results for any period. Pro forma results are: Year Ended December 31, 2022 2021 Net services revenue $ 2,009.7 $ 1,813.5 Net loss $ (55.0) $ (177.5) Adjustments were made to earnings to adjust depreciation and amortization to reflect the fair value of identified assets acquired, to adjust share-based compensation expense for awards granted in connection with the acquisitions, to record the effects of extinguishing the debt of the acquired companies and replacing it with the debt of the Company, to adjust timing of acquisition related costs incurred by the Company, and to record the income tax effect of these adjustments.

Intangible Assets

Intangible Assets	12 Months Ended
	Dec. 31, 2022
Goodwill and Intangible Assets Disclosure [Abstract]
Intangible Assets	Intangible Assets The following table provides the gross carrying value and accumulated amortization for each major class of definite-lived intangible assets at December 31, 2022 and December 31, 2021: December 31, 2022 December 31, 2021 Gross Carrying Value Accumulated Amortization Net Book Value Gross Carrying Value Accumulated Amortization Net Book Value Customer relationships $ 418.0 $ (36.3) $ 381.7 $ 100.0 $ (20.8) $ 79.2 Technology 1,240.5 (129.3) 1,111.2 215.5 (30.2) 185.3 Tradename 24.5 (3.0) 21.5 1.0 (0.1) 0.9 Favorable leasehold interests 0.1 — 0.1 — — — Total intangible assets $ 1,683.1 $ (168.6) $ 1,514.5 $ 316.5 $ (51.1) $ 265.4 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, customer relationships, tradename, and favorable leasehold interests. Intangible asset amortization expense was $117.4 million, $22.9 million, and $18.1 million for the years ended December 31, 2022, 2021, and 2020 respectively. Amortization expense for intangible assets is included in cost of services on the Company’s Consolidated Statements of Operations and Comprehensive Income (Loss). The Company has no indefinite-lived intangible assets. Estimated annual amortization expense related to intangible assets with definite lives as of December 31, 2022 is as follows: 2023 $ 197.2 2024 195.3 2025 193.7 2026 193.7 2027 191.2 Thereafter 543.4 Total $ 1,514.5

Goodwill

Goodwill	12 Months Ended
	Dec. 31, 2022
Goodwill and Intangible Assets Disclosure [Abstract]
Goodwill	Goodwill Goodwill represents the difference between the purchase price of acquired companies and the related fair value of the net assets acquired, which applies the acquisition method of accounting. Changes in the carrying amount of goodwill for the year ended December 31, 2022 were: Goodwill Balance as of December 31, 2021 $ 554.7 Cloudmed Acquisition 2,103.6 Change in foreign currency rates (0.1) Balance as of December 31, 2022 $ 2,658.2

Revenue Recognition

Revenue Recognition	12 Months Ended
	Dec. 31, 2022
Revenue from Contract with Customer [Abstract]
Revenue Recognition	Revenue Recognition Disaggregation of Revenue In the following table, revenue is disaggregated by source of revenue: Year Ended December 31, 2022 2021 2020 Net operating fees $ 1,309.7 $ 1,211.8 $ 1,093.8 Incentive fees 106.8 143.8 70.6 Modular and other (1) 389.9 119.0 106.4 Net services revenue $ 1,806.4 $ 1,474.6 $ 1,270.8 (1) Modular and other revenue primarily consists of service fees related to Cloudmed and revenue integrity solutions, PM services, PAS, and software subscription revenue. Contract Balances The following table provides information about contract assets, net and contract liabilities from contracts with customers: December 31, 2022 December 31, 2021 Contract assets, net Current $ 83.9 $ — Non-current 32.0 — Total contract assets, net $ 115.9 $ — Contract liabilities Current (1) $ 9.7 $ 10.3 Non-current (2) 18.7 18.7 Total contract liabilities $ 28.4 $ 29.0 (1) Current contract liabilities include $7.6 million and $7.8 million classified in the current portion of customer liabilities and $2.1 million and $2.5 million classified in the current portion of customer liabilities - related party as of December 31, 2022 and 2021, respectively. (2) Non-current contract liabilities include $5.0 million and $3.3 million classified in the non-current portion of customer liabilities and $13.7 million and $15.4 million classified in the non-current portion of customer liabilities - related party as of December 31, 2022 and 2021, respectively. The contract assets, net balance will increase or decrease based on the timing of invoices and recognition of revenue. Prior to the Cloudmed Acquisition, the Company did not have significant contract assets. Significant changes in the carrying amount of contract assets, net for the six months ended December 31, 2022 were as follows: Contract Assets Balance as of June 30, 2022 $ 89.6 Revenue recognized 172.9 Amounts billed (151.0) Other (1) 4.4 Balance as of December 31, 2022 $ 115.9 (1) Other primarily includes measurement period adjustments to the contract assets acquired from the Cloudmed Acquisition. A contract asset is recorded when the Company has recognized revenue but does not yet have the right to invoice. 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 $94.8 million and $98.0 million during the years ended December 31, 2022 and 2021, which amounts were included in contract liabilities on January 1 of the respective periods. These revenue amounts include $85.8 million and $88.1 million for the years ended December 31, 2022 and 2021, respectively, related to advanced billings which become accounts receivable and contract liabilities on the first day of the respective service period. Refer to Note 3, Acquisitions, for the preliminary contract assets acquired and contract liabilities assumed as part of the Cloudmed Acquisition. 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. The estimated revenue does not include amounts of variable consideration that are constrained. Net operating fees Incentive fees 2023 $ 115.4 $ 27.0 2024 82.5 — 2025 39.3 — 2026 38.2 — 2027 34.1 — Thereafter 124.9 — Total $ 434.4 $ 27.0 The amounts presented in the table above include variable fee estimates of the Company’s physician groups RCM services contracts, fixed fees, and forecasted incentive fees. Fixed fees are typically recognized ratably as the performance obligation is satisfied and forecasted incentive fees 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. 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 solutions 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 solutions 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.

Accounts Receivable and Allowan

Accounts Receivable and Allowance for Credit Losses	12 Months Ended
	Dec. 31, 2022
Receivables [Abstract]
Accounts Receivable and Allowance for Credit Losses	Accounts Receivable and Allowance for Credit Losses Accounts receivable is comprised of unpaid balances pertaining to modular solutions and end-to-end RCM customers, 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 PM 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 business and industry 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. During the year ended December 31, 2022, the Company increased the allowance for credit losses related to a physician customer by $9.6 million due to the customer facing financial challenges and its resulting inability to make a contractually required payment during the year. As a result of reviewing the potential expected outcomes related to this customer, the Company holds an allowance for credit losses of $10.1 million related to an overall receivable balance of $32.6 million as of December 31, 2022 . 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 related to accounts receivable are as follows: Year Ended December 31, 2022 2021 Beginning balance $ 2.5 $ 3.8 Cumulative effect of Cloudmed ASC 326 adoption 1.8 — Provision (recoveries) 11.1 0.7 Write-offs (0.2) (2.0) Ending balance $ 15.2 $ 2.5

Leases

Leases	12 Months Ended
	Dec. 31, 2022
Leases [Abstract]
Leases	Leases The Company determines if an arrangement is a lease at inception. The Company has operating leases for corporate offices, operational facilities, global business services centers, and certain equipment. Operating leases with terms greater than one year at commencement are included in operating lease ROU assets and operating lease liabilities (current and non-current) on the Consolidated Balance Sheets. Operating 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. For leases with an initial term of 12 months or less, expense is recognized on a straight-line basis over the lease term. Leases have remaining lease terms of up to 11 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: Year Ended December 31, 2022 2021 Operating lease cost $ 22.1 $ 15.8 Sublease income (1.6) (2.3) Total lease cost $ 20.5 $ 13.5 The following table summarizes the supplemental information related to operating leases: Year Ended December 31, 2022 2021 Weighted average remaining lease term 7 years 7 years Weighted average incremental borrowing rate 6.52 % 8.10 % Cash paid for amounts included in the measurement of lease liabilities: Operating cash flows for operating leases $ 27.0 $ 22.8 ROU assets obtained or acquired in exchange for operating lease obligations (1) 67.7 20.3 (1) This amount includes ROU assets acquired from the Cloudmed Acquisition. For details on the preliminary ROU assets acquired and liabilities assumed, refer to Note 3, Acquisitions. The Company presents all non-cash charges related to any modification or reassessment events triggering remeasurement, and obtaining new leases for non-cash consideration that result in adjustments to the lease liability or ROU asset as non-cash transactions. As part of evaluating its footprint, the Company exited certain leased facilities. During the three months ended December 31, 2022, the Company recorded ROU asset and related leasehold improvement impairments of $17.0 million as a result of decisions to exit various leases acquired as part of the Cloudmed Acquisition. Maturities of lease liabilities as of December 31, 2022 are as follows: Operating Leases 2023 $ 24.6 2024 23.9 2025 22.6 2026 16.8 2027 10.7 Thereafter 40.7 Total 139.3 Less: Imputed interest 26.9 Present value of lease liabilities $ 112.4

Customer Liabilities

Customer Liabilities	12 Months Ended
	Dec. 31, 2022
Other Liabilities Disclosure [Abstract]
Customer Liabilities	Customer Liabilities Customer 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) customer deposits (consisting of amounts due as a refund to the Company’s customers on base fees and incentive fees), (iv) refund liabilities (amounts potentially 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: December 31, 2022 December 31, 2021 Accrued service costs, current $ 21.9 $ 32.3 Collections payable to clients, current 29.1 3.0 Customer deposits, current 1.5 — Refund liabilities, current 2.7 3.8 Deferred revenue (contract liabilities), current 9.7 10.3 Current portion of customer liabilities (1) 64.9 49.4 Deferred revenue (contract liabilities), non-current 18.7 18.7 Non-current portion of customer liabilities (1) 18.7 18.7 Total customer liabilities $ 83.6 $ 68.1 (1) Current and non-current portion of customer liabilities include amounts for a related party. See Note 19, Related Party Transactions, for further discussion.

Debt

Debt	12 Months Ended
	Dec. 31, 2022
Debt Disclosure [Abstract]
Debt	Debt The carrying amounts of debt consist of the following: December 31, 2022 December 31, 2021 Senior Revolver (1) $ 100.0 $ 80.0 Term A Loans 1,211.4 695.6 Term B Loan 498.7 — Unamortized discount and issuance costs (23.6) (3.2) Total debt 1,786.5 772.4 Less: Current maturities (53.9) (17.5) Total long-term debt $ 1,732.6 $ 754.9 (1) As of December 31, 2022, the Company had $100.0 million in borrowings, $0.9 million letters of credit outstanding, and $499.1 million of availability under the senior secured revolving credit facility (“Senior Revolver”). Second Amended and Restated Senior Secured Credit Facilities On July 1, 2021, the Company and certain of its subsidiaries entered into an amended and restated senior credit agreement (the “A&R Credit Agreement”) with Bank of America, N.A., as administrative agent, and the lenders named therein, and governing credit facilities consisting of a $700.0 million senior secured term loan facility and a $450.0 million senior revolver. The proceeds from the A&R Credit Agreement, in addition to cash on hand, were used to refinance, in full, all debt under the existing credit agreement, which consisted of a $325.0 million senior secured term loan facility and a $100.0 million senior secured revolving credit facility, and to fund the VisitPay acquisition. For the year ended December 31, 2021, the carrying amounts of debt presented in the table above were incurred under the A&R Credit Agreement. On June 21, 2022, the Company and certain of its subsidiaries entered into a second amended and restated senior credit agreement (the “Second A&R Credit Agreement”) with Bank of America, N.A., as administrative agent, and the lenders named therein, governing the Company’s second amended and restated senior secured credit facilities (the “Senior Secured Credit Facilities”), was executed and consisted of the $691.3 million existing senior secured term loan A facility (the “Existing Term A Loan”), a $540.0 million senior secured incremental term loan A facility (the “Incremental Term A Loan,” and together with the Existing Term A Loan, the “Term A Loans”), a $500.0 million senior secured term loan B facility (the “Term B Loan,” and together with the Term A Loans, the “Senior Term Loans”), and a $600.0 million Senior Revolver. In conjunction with entering into the Second A&R Credit Agreement, the Company incurred $7.2 million and capitalized $6.4 million of debt issuance costs. The Incremental Term A Loan has a five-year maturity and the Term B Loan has a seven-year maturity. The Existing Term A Loan and Senior Revolver mature on July 1, 2026. The Second A&R 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. 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 Term Secured Overnight Financing Rate (“SOFR”) for an interest period of one-month beginning on such day plus 100 basis points, plus between 0.25% and 1.50% dependent on the Company’s total net leverage ratio (provided that the Term SOFR rate applicable to the Term A Loans shall not be less than 0.00% per annum, and the Term SOFR rate applicable to the Term B Loan shall not be less than 0.50% per annum); or (ii) the Term SOFR rate (provided that the Term SOFR rate applicable to the Term A Loans shall not be less than 0.00% per annum, and the Term SOFR rate applicable to the Term B Loan shall not be less than 0.50% per annum), plus between 1.25% and 2.50%, dependent on the Company’s total net leverage ratio. The interest rate as of December 31, 2022 was 6.57% for the Term A Loans and Senior Revolver and 7.32% for the Term B Loan. The Company is also required to pay an unused commitment fee to the lenders under the Senior Revolver at a rate between 0.20% and 0.40% of the average daily unutilized commitments thereunder dependent on the Company’s total net leverage ratio. The Second A&R Credit Agreement requires the Company to make mandatory prepayments, subject to certain exceptions, with: (i) beginning with fiscal year ending December 31, 2023, 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 asset 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 Second A&R Credit Agreement. The Second A&R Credit Agreement contains several financial and non-financial covenants. The Company was in compliance with all of the covenants in the Second A&R Credit Agreement as of December 31, 2022. The obligations under the Second A&R Credit Agreement 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 certain domestic subsidiaries. The proceeds from the new Senior Secured Credit Facilities were or will be used, in addition to cash on hand, (1) to refinance, in full, all existing indebtedness under the A&R Credit Agreement, and amend and restate all commitments thereunder (the “Refinancing”), (2) to pay certain fees and expenses incurred in connection with the entry into the Second A&R Credit Agreement and the Refinancing, (3) to fund the 2022 Transactions, and to pay the fees, premiums, expenses, and other transaction costs incurred in connection therewith, and (4) to finance working capital needs of the Company and its subsidiaries for general corporate purposes. Debt Maturities Scheduled maturities of the Company’s long-term debt for each of the five years succeeding December 31, 2022 and thereafter are summarized as follows: Scheduled Maturities 2023 $ 53.9 2024 67.0 2025 67.0 2026 718.3 2027 430.2 Thereafter 473.7 Total $ 1,810.1

Derivative Financial Instrument

Derivative Financial Instruments	12 Months Ended
	Dec. 31, 2022
Derivative Instruments and Hedging Activities Disclosure [Abstract]
Derivative Financial Instruments	Derivative Financial Instruments The Company actively manages the risk of changes in foreign currency exchange rates and change in interest rates through non-deliverable 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. Positions are monitored using techniques such as market value and sensitivity analyses. The Company does not enter into derivative transactions for speculative purposes. 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 during the period in which the hedged transaction impacts earnings. 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 Company utilizes cash flow hedges to manage its currency risk arising from its global business services centers. As of December 31, 2022, the Company has recorded $0.4 million of unrealized losses in accumulated other comprehensive income related to foreign currency hedges. The Company estimates that $0.4 million of losses reported in accumulated other comprehensive income are expected to be reclassified into earnings within the next 12 months. Amounts reclassified into cost of services were a net loss of $1.4 million and a net gain of $1.4 million for the years ended December 31, 2022 and 2021, respectively. As of December 31, 2022, the Company’s foreign currency forward contracts have maturities extending no later than December 31, 2023, and had total notional value of $126.4 million. As of December 31, 2021, the total notional amount of the Company’s foreign currency forward contracts was $84.3 million. The Company also utilizes cash flow hedges to reduce variability in interest cash flows from its outstanding debt. As of December 31, 2022, the Company has recorded $13.7 million of unrealized gains in accumulated other comprehensive income related to interest rate swaps. The Company estimates that $8.7 million of gains reported in accumulated other comprehensive income are expected to be reclassified into earnings within the next 12 months. Amounts reclassified into interest expense were a net loss of $0.2 million and $1.5 million for the years ended December 31, 2022 and 2021. As of December 31, 2022, the Company’s interest rate swaps extend no later than June 30, 2025 and had total notional amounts of $500.0 million. As of December 31, 2021, the total notional amount of the Company’s interest rate swaps was $100.0 million. The location and fair value of derivative instruments designated as hedges in the Consolidated Balance Sheets as of December 31, 2022 and December 31, 2021 are as follows: December 31, 2022 December 31, 2021 Foreign currency forward contracts Prepaid expenses and other current assets $ 0.1 $ 1.7 Other accrued expenses 0.5 — Total foreign current forward contracts $ 0.6 $ 1.7 Interest rate swaps Prepaid expenses and other current assets $ 8.7 $ — Other assets 5.0 — Other accrued expenses — 0.7 Total interest rate swaps $ 13.7 $ 0.7 As of December 31, 2022 and December 31, 2021, the accumulated gain, net of tax, recognized in accumulated other comprehensive loss was $9.9 million and $0.7 million, respectively. 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, 2022, the Company held no derivatives, or non-derivative hedging instruments, that were designated in fair value or net investment hedges.

Stockholders' Equity

Stockholders' Equity	12 Months Ended
	Dec. 31, 2022
Equity [Abstract]
Stockholders' Equity	Stockholders’ Equity Preferred Stock and Warrants As of December 31, 2022 and 2021, the Company had 5,000,000 shares of authorized preferred stock, 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 2016 Transaction, the Company issued to TCP-ASC ACHI Series LLLP (“TCP-ASC”), a limited liability limited partnership jointly owned by Ascension Health Alliance and investment funds affiliated with TowerBrook: (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 was immediately convertible into shares of common stock. As of December 31, 2022 and 2021, the Company had zero shares of Series A Preferred Stock outstanding. The Series A Preferred Stock was converted to common stock on January 15, 2021. See Note 16, 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, 2022 and 2021, 42.0 million total warrants were outstanding for TCP-ASC and Intermountain. Common Stock Each outstanding share of the Company’s common stock, par value $0.01 per share, 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 2022 or 2021. 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 “2013 Repurchase Program”). Between October 1, 2021 and October 27, 2021, the Company finalized authorized repurchases under the 2013 Repurchase Program. On October 22, 2021, the Board adopted a new repurchase program and authorized the repurchase of up to $200.0 million of our common stock from time to time in the open market or in privately negotiated transactions (the “2021 Repurchase Program”). On January 9, 2022, the Board increased the authorization under the 2021 Repurchase Program to an aggregate amount of up to $500.0 million. The timing and amount of any shares repurchased under the 2021 Repurchase Program will be determined by the Company’s management based on its evaluation of market conditions and other factors. The 2021 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, 2022 and 2021, 2,080,518 and 2,629,257 shares were repurchased, respectively. No shares have been retired. As of December 31, 2022 and 2021, the Company held in treasury 10,031,168 and 7,950,650 shares of repurchased stock, respectively. Treasury stock also includes repurchases of Company stock related to employees’ tax withholding upon vesting of restricted shares. For the years ended December 31, 2022 and 2021, the Company repurchased 1,174,754 and 796,908 shares related to employees’ tax withholding upon vesting of restricted shares, respectively. See Note 13, Share-Based Compensation, for additional information.

Share-Based Compensation

Share-Based Compensation	12 Months Ended
	Dec. 31, 2022
Share-Based Payment Arrangement [Abstract]
Share-Based Compensation	Share-Based Compensation The Company maintains three stock incentive plans: the Amended and Restated Stock Option Plan (the “2006 Plan”), the Third Amended and Restated Stock 2010 Incentive Plan (the “2010 Amended Plan,” together with the 2006 Plan, the “Plans”), and the R1 RCM Inc. 2022 Inducement Plan (the “Inducement Plan”). 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. On May 20, 2021, the Company’s stockholders approved the Third Amended and Restated 2010 Stock Incentive Plan, which amended and restated the Company’s Second Amended and Restated 2010 Stock Incentive Plan and authorized the issuance of an additional 9.6 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 55,974,756 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, Restricted Stock Awards, RSUs, and other share-based awards. As of December 31, 2022, 7,348,028 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 and RSUs vest ratably between one On June 21, 2022, the Board adopted the Inducement Plan to accommodate equity grants to new employees of the Company hired in connection with the 2022 Transactions. Under the Inducement Plan, the Company may grant RSUs (including PBRSUs) with respect to up to a total of 6,225,000 shares of common stock to new employees. Pursuant to Rule 5635(c)(4) of the NASDAQ Listing Rules, the Inducement Plan was adopted without stockholder approval. The Inducement Plan only provides for the grant of RSUs (including PBRSUs), and its terms are otherwise substantially similar to the 2010 Amended Plan, including with respect to treatment of equity awards in the event of a “change in control” as defined under the Inducement Plan. In accordance with Rule 5635(c)(4) of the NASDAQ Listing Rules, awards under the Inducement Plan can only be made to individuals not previously employees or non-employee directors of the Company (or following such individuals’ bona fide period of non-employment with the Company), as an inducement material to the individuals’ entry into employment with the Company or in connection with a merger or acquisition, to the extent permitted by Rule 5635(c)(3) of the NASDAQ Listing Rules. As of December 31, 2022, 259,372 shares were available for future grants of awards under the Inducement Plan. However, to the extent that previously granted awards under the Inducement Plan expire, terminate or are otherwise surrendered, canceled or forfeited, the number of shares available for future awards under the Inducement Plan will increase. For the years ended December 31, 2022, 2021, and 2020, the Company recognized $9.8 million, $12.7 million, and $37.3 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 their grant dates. The volatility for the options was calculated based on an analysis of historical volatility. The Company assesses current performance on performance-based PBRSUs by reviewing historical performance to date, along with any adjustments which have been approved to the reported performance, and changes to the 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. A Monte Carlo simulation was used to estimate the fair value of the Unvested Units, which are being amortized over a period of 4 years on a straight-line basis. The volatility for the Unvested Units was calculated based on an analysis of historical and implied volatility. The following table sets forth the significant assumptions used in the calculation of share-based compensation expense during 2022, 2021, and 2020: Year Ended December 31, 2022 2021 2020 Expected dividend yield —% —% —% Risk-free interest rate 1.4% to 3.3% 0.4% to 1.0% 0.3% to 1.7% Expected volatility 43% to 50% 43% 43% Expected term (in years) 4.0 to 5.5 5.5 5.5 Total share-based compensation costs that have been included in the Company’s consolidated statements of operations were as follows: Year Ended December 31, 2022 2021 2020 Share-Based Compensation Expense Allocation Details: Cost of services $ 28.8 $ 44.2 $ 9.9 Selling, general and administrative 38.2 30.1 14.1 Other 0.1 — 0.1 Total share-based compensation expense (1) $ 67.1 $ 74.3 $ 24.1 (1) Included in the share-based compensation expense above is $5.1 million of CoyCo 2 share-based compensation expense for the year ended December 31, 2022. See further discussion below. In addition to the share-based compensation expense recorded above, $0.3 million , $0.6 million, and $0.1 million of share-based compensation expense was capitalized to deferred contract costs for the years ended December 31, 2022 , 2021, and 2020, respectively. See Note 2, Summary of Significant Accounting Policies, 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, 2022, 2021, and 2020: Shares Weighted- Weighted- Aggregate Outstanding at January 1, 2020 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 Granted 6,424 23.33 Exercised (1,819,039) 4.39 Canceled/forfeited (15,151) 5.98 Expired (7,000) 27.08 Outstanding at December 31, 2021 4,386,205 $ 3.37 4.9 $ 97.0 Granted 24,344 22.19 Exercised (1,285,228) 3.67 Canceled/forfeited (13,408) 4.59 Expired (7,500) 8.71 Outstanding at December 31, 2022 3,104,413 $ 3.38 4.0 $ 23.9 Outstanding, vested and exercisable at December 31, 2020 5,230,690 $ 3.73 5.5 $ 106.2 Outstanding, vested and exercisable at December 31, 2021 4,365,759 $ 3.33 4.9 $ 96.7 Outstanding, vested and exercisable at December 31, 2022 3,080,069 $ 3.23 4.0 $ 23.9 The weighted-average grant date fair value of options granted during the years ended December 31, 2022, 2021, and 2020 was $9.55, $9.34, and $4.41 per share, respectively. The total intrinsic value of the options exercised in the years ended December 31, 2022, 2021, and 2020 was $26.5 million, $38.2 million, and $30.5 million, respectively. The total fair value of options vested during the years ended December 31, 2022, 2021, and 2020 was $0.1 million, $1.4 million, and $2.2 million, respectively. Restricted stock units and performance-based restricted stock units The following table sets forth a summary of all RSU and PBRSU activity during the years ended December 31, 2022, 2021, and 2020: Weighted- RSUs PBRSUs RSU PBRSU Outstanding and unvested at January 1, 2020 1,373,356 4,119,436 $ 8.03 $ 6.37 Granted 1,588,120 1,637,581 10.29 13.25 Performance factor adjustment — 3,879,186 — 14.72 Vested (504,708) (6,344,151) 6.74 13.11 Forfeited (348,321) (374,981) 9.09 6.66 Outstanding and unvested at December 31, 2020 2,108,447 2,917,071 $ 9.87 $ 11.35 Granted 2,251,167 1,071,431 24.35 25.36 Performance factor adjustment — 101,937 — 9.81 Vested (1,739,847) (586,071) 19.14 7.67 Forfeited (401,116) (301,355) 15.48 13.55 Outstanding and unvested at December 31, 2021 2,218,651 3,203,013 $ 16.28 $ 16.45 Granted 2,306,897 5,230,483 20.56 19.83 Performance factor adjustment — 876,109 — 10.46 Vested (1,029,491) (1,925,203) 16.61 11.05 Forfeited (264,055) (507,605) 18.22 20.38 Outstanding and unvested at December 31, 2022 3,232,002 6,876,797 $ 19.07 $ 19.48 Shares surrendered for taxes for year ended December 31, 2022 369,900 804,854 Cost of shares surrendered for taxes for the year ended December 31, 2022 (in millions) 7.4 20.2 Shares surrendered for taxes for the year ended December 31, 2021 571,182 225,726 Cost of shares surrendered for taxes for the year ended December 31, 2021 (in millions) 13.5 5.6 Shares surrendered for taxes for the year ended December 31, 2020 141,331 2,740,924 Cost of shares surrendered for taxes for the year ended December 31, 2020 (in millions) 1.4 64.2 Upon consummation of the Holding Company Reorganization, outstanding restricted units of Cloudmed were replaced by an aggregate 1,536,220 RSUs of the Company. The Company also issued an aggregate of 3,173,184 inducement RSUs and PBRSUs to certain employees of Cloudmed under Nasdaq Listing Rule 5635(c)(4) pursuant to its newly adopted 2022 Inducement Plan. The Company’s RSU and PBRSU agreements allow employees to surrender to the Company shares of common stock upon vesting of their RSUs and PBRSUs in lieu of their payment of the required personal employment-related taxes. Shares surrendered for payment of personal employment-related taxes are held in treasury. Outstanding PBRSUs vest 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, modular sales revenue, 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 13,753,594. CoyCo 2, L.P. Limited Partnership Units Former Class P Units were originally issued to employees of Cloudmed and its affiliates (“Participants”) in connection with and as a part of the compensation and incentive arrangements between Cloudmed and such Participants prior to the consummation of the Cloudmed Acquisition. A portion of the Former Class P Units immediately vested upon the closing of the Cloudmed Acquisition. In connection with the Cloudmed Acquisition, Cloudmed caused the Former Class P Units, including the Unvested Units, to be converted into Management Units. At the time of the closing of the Cloudmed Acquisition, 97,875 Unvested Units were converted into 514,986 Management Units.

Other Expenses

Other Expenses	12 Months Ended
	Dec. 31, 2022
Other Income and Expenses [Abstract]
Other Expenses	Other Expenses Other expenses are incurred in connection with acquisition and integration costs, various exit activities, transformation initiatives, and organizational changes to improve our business alignment and cost structure. The following table summarizes the other expenses (income) recognized for the years ended December 31, 2022, 2021, and 2020: Year Ended December 31, 2022 2021 2020 Severance and related employee benefits (1) $ 1.2 $ 2.2 $ 6.4 Business acquisition costs (2) 74.5 4.0 16.7 Integration costs (3) 40.2 2.6 5.4 Strategic initiatives (4) 23.2 9.1 7.2 Global business services center expansion project in the Philippines (5) 26.7 1.8 — Customer employee transition and restructuring expenses (6) (0.4) 4.9 (0.2) Facility-exit charges (7) 7.9 3.4 17.5 Other (8) 10.2 18.1 14.3 Total other expenses $ 183.5 $ 46.1 $ 67.3 (1) These costs relate to restructuring and business reorganization events. (2) These are costs, including legal, consulting, and bank fees, that are directly related to the closing of business acquisitions and include changes to contingent consideration. (3) These costs reflect efforts to integrate acquisitions from a systems, processes, and people perspective and to achieve synergies expected from the transaction. Costs include consulting fees, IT vendor spend, severance, early lease termination of Cloudmed facilities, and certain payroll costs. (4) These costs relate to performing portfolio and capital structure analyses and transactions and other business transformation projects (including large scale system projects) as part of the Company’s growth strategy. Costs include vendor spend, employee time and expenses spent on activities, severance, and retention amounts. (5) These costs include legal and consulting fees related to the establishment of the Company’s inaugural global business services center in the Philippines as well as severance costs for personnel whose roles are being relocated. The entry into the Philippines is the first new organic global business services center country expansion by the Company in approximately 15 years. (6) As part of the transition of customer personnel to the Company under certain operating partner model contracts, the Company agreed to reimburse the customer, or directly pay affected employees, for severance and retention costs related to certain employees who were not transitioned to the Company, or whose jobs were relocated after the employee transitioned to the Company. (7) As part of evaluating its footprint, the Company has exited certain leased facilities. Costs include asset impairment charges, early termination fees, and other costs related to exited leased facilities (excluding early lease termination of Cloudmed facilities, which is included in (3) above). (8) For the years ended December 31, 2022, 2021, and 2020, other includes $2.5 million, $11.3 million, and $10.9 million, respectively, of expenses related to the COVID-19 pandemic.

Income Taxes

Income Taxes	12 Months Ended
	Dec. 31, 2022
Income Tax Disclosure [Abstract]
Income Taxes	Income Taxes The domestic and foreign components of income (loss) before income taxes consist of the following: Year Ended December 31, 2022 2021 2020 Domestic $ (81.0) $ 110.1 $ 99.4 Foreign 20.0 16.7 19.0 Total income (loss) before income taxes $ (61.0) $ 126.8 $ 118.4 For the years ended December 31, 2022, 2021, and 2020, the Company’s current and deferred income tax expense (benefit) attributable to income from operations are as follows: Current Deferred Total 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 Year Ended December 31, 2021 U.S. Federal $ (0.1) $ 21.7 $ 21.6 State & Local 3.4 — 3.4 Foreign 3.0 1.6 4.6 $ 6.3 $ 23.3 $ 29.6 Year Ended December 31, 2022 U.S. Federal $ 0.9 $ (11.5) $ (10.6) State & Local 3.9 (5.0) (1.1) Foreign 3.2 5.1 8.3 $ 8.0 $ (11.4) $ (3.4) 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, 2022 2021 2020 Federal statutory tax rate 21 % 21 % 21 % Change in income tax rate resulting from: State and local income taxes, net of federal tax benefits 1 % 2 % 1 % Additional tax on foreign source income (12) % 3 % 3 % Share-based compensation 20 % (8) % (24) % Non-deductible expenses (23) % 5 % 13 % Gain on sale — % — % (11) % Other (1) % — % (2) % Effective tax rate 6 % 23 % 1 % The following table sets forth the Company’s net deferred tax as of December 31, 2022 and 2021: As of December 31, 2022 2021 Deferred tax assets and liabilities: Net operating loss carryforwards $ 50.0 $ 54.7 Share-based compensation 16.6 12.2 Accrued bonus 13.7 8.5 Advanced billing revenue 6.8 7.2 Alternative minimum tax 6.2 6.4 Interest expense limitation 11.1 0.1 Deferred rent liabilities 29.1 19.3 Deferred FICA liability — 3.0 Fixed assets 1.0 — Other 13.1 12.3 Total deferred tax assets 147.6 123.7 Intangible assets (292.6) (41.7) Fixed assets — (1.5) Deferred contract costs (8.0) (8.7) Foreign withholding tax (10.2) (4.2) Deferred rent assets (20.0) (13.6) Less valuation allowances (7.1) (6.4) Net deferred tax $ (190.3) $ 47.6 At December 31, 2022, the Company had cumulative U.S. federal and state net operating loss (“NOL”) carryforwards of approximately $181.5 million and $223.4 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 2024. 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, 2022 and 2021 of $7.1 million and $6.4 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. The December 31, 2022 valuation allowance includes $3.4 million attributable to research and development credits and $2.2 million for a capital loss. The 2022, 2021, and 2020 foreign current tax provision includes $3.2 million, $3.0 million, and $2.4 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 $4.9 million, $4.7 million, and $4.3 million for the years ended December 31, 2022, 2021, and 2020, respectively. The tax holidays are set to expire between March 31, 2024 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, 2022, 2021, and 2020 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 2018 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, 2022
Temporary Equity Disclosure [Abstract]
8.00% Series A Convertible Preferred Stock	8.00% Series A Convertible Preferred Stock At the close of the 2016 Transaction on February 16, 2016 (as described in Note 1), the Company issued to TCP-ASC: (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, TCP-ASC converted all of its 294,266 shares of Preferred Stock into 117,706,400 shares of common stock of the Company into which the 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 TCP-ASC, and (ii) paid TCP-ASC $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. The consideration paid to induce the conversion was recorded as a dividend of $592.3 million and reduced income available to common shareholders in our earnings per share calculation. The dividend was calculated as the cash paid of $105.0 million plus the fair value on the conversion date of the additional 21,582,800 shares of common stock issued as consideration for the conversion. 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, the Company had accrued dividends of $5.8 million associated with the Preferred Stock, of which $5.8 million was paid in additional shares and $940 was paid in cash in January 2021. For the year ended December 31, 2020, the dividends paid, or accrued, in additional shares of Preferred Stock totaled $22.4 million. The following summarizes the Preferred Stock activity for the years ended December 31, 2021 and 2020: Preferred Stock Shares Issued and Outstanding Carrying Value Balance at January 1, 2020 266,529 $ 229.1 Dividends paid/accrued dividends 21,968 22.4 Balance at December 31, 2020 288,497 $ 251.5 Dividends paid/accrued dividends 5,769 — Conversion of Preferred Stock (294,266) (251.5) Balance at December 31, 2021 — $ —

Earnings (Loss) Per Share

Earnings (Loss) Per Share	12 Months Ended
	Dec. 31, 2022
Earnings Per Share [Abstract]
Earnings (Loss) Per Share	Earnings (Loss) Per ShareBasic net income (loss) per share is computed by dividing net income (loss), 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 participated in dividends alongside the Company’s common stock (per their participating dividends), the preferred stock constituted participating securities under ASC 260-10, Earnings Per Share, and were applied to earnings per share using the two-class method. Under this method, all earnings (distributed and undistributed) were allocated to common shares and participating securities based on their respective rights to receive dividends. Diluted net income (loss) per share is calculated by adjusting the denominator used in the basic net income (loss) 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 RSUs and PBRSUs, and shares issuable upon conversion of preferred stock. Basic and diluted net income (loss) per common share are calculated as follows: Year Ended December 31, 2022 2021 2020 Basic EPS: Net income (loss) $ (57.6) $ 97.2 $ 117.1 Less dividends on preferred shares (1) — (592.3) (22.4) Less income allocated to preferred shareholders — — (47.3) Net income (loss) available/(allocated) to common shareholders - basic $ (57.6) $ (495.1) $ 47.4 Diluted EPS: Net income (loss) $ (57.6) $ 97.2 $ 117.1 Less dividends on preferred shares (1) — (592.3) (22.4) Less income allocated to preferred shareholders — — (37.7) Net income (loss) available/(allocated) to common shareholders - diluted $ (57.6) $ (495.1) $ 57.0 Basic weighted-average common shares 352,337,767 266,183,565 115,729,645 Add: Effect of dilutive equity awards — — 12,731,424 Add: Effect of dilutive warrants — — 46,112,201 Diluted weighted average common shares 352,337,767 266,183,565 174,573,270 Net income (loss) per common share (basic) $ (0.16) $ (1.86) $ 0.41 Net income (loss) per common share (diluted) $ (0.16) $ (1.86) $ 0.33 (1) The 2021 dividend on preferred shares includes amounts related to the conversion of the preferred shares. See Note 16, 8.00% Series A Convertible Preferred Stock, for more information. Because of their anti-dilutive effect, 20,090,009, 12,875,730, 97,244 common share equivalents comprised of stock options, PBRSUs, and RSUs have been excluded from the diluted earnings per share calculation for the years ended December 31, 2022, 2021, and 2020, respectively. Additionally, for the years ended December 31, 2022 and 2021, warrants to acquire up to 42.0 million shares of the Company’s common stock have been excluded from the diluted earnings per share calculation because they were anti-dilutive.

Commitments and Contingencies

Commitments and Contingencies	12 Months Ended
	Dec. 31, 2022
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. On April 13, 2021 and April 19, 2021, respectively, certain purported stockholders of the Company filed two complaints in the Delaware Court of Chancery regarding the Company’s January 15, 2021 recapitalization transaction with TCP-ASC. Both complaints allege that TCP-ASC, Ascension, and TowerBrook controlled the Company and breached their fiduciary duties by using that alleged control to force the Company to overpay in redeeming TCP-ASC’s preferred stock as part of the recapitalization transaction. The plaintiffs seek an unspecified amount of damages against TCP-ASC, Ascension, and TowerBrook. The plaintiffs also allege that the Company and TCP-ASC entered into amendments to the Investor Rights Agreement that the plaintiffs contend contain provisions that are void under the Company’s charter, bylaws, and the Delaware General Corporation Law. The cases have since been consolidated into a single action. All defendants have answered the Complaint and discovery has commenced. On February 18, 2022, plaintiffs filed a supplement to their complaint, naming certain additional defendants and asserting additional claims related to the Company’s agreement to acquire Cloudmed, which was announced on January 10, 2022. The additional claims assert that: (i) TCP-ASC, Ascension, and Towerbrook, along with the Company’s directors (“Individual Defendants”), breached their fiduciary duties by causing the Company to enter into and approving the Cloudmed acquisition, respectively, which plaintiffs claim will perpetuate TCP-ASC’s, Ascension’s, and Towerbrook’s control over the Company and entrench the Individual Defendants by virtue of certain agreements entered into as part of the transaction, including a Second Amended Investor Rights Agreement with TCP-ASC (the “Seconded Amended Investor Rights Agreement”) and an Investor Rights Agreement with Cloudmed (the “Cloudmed Investor Rights Agreement”); and (ii) Cloudmed’s stockholders aided and abetted such breaches. Plaintiffs also allege that certain provisions in the Cloudmed Investor Rights Agreement and the Second Amended Investor Rights Agreement are void under the Company’s charter, bylaws, and the Delaware General Corporation law.The plaintiffs seek a declaratory judgment and an unspecified amount of damages, as well as attorneys’ fees and costs. The Company believes it has meritorious defenses to all claims against it and intends to vigorously defend itself against these claims. 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 customers ( 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. Both the Company’s and plaintiff’s motions for summary judgment were denied in December 2020, and the parties have completed damage and expert discovery. Additional dispositive motions are expected to extend into 2023, with trial, if necessary, in mid-to-late 2023. The Company believes it has meritorious defenses to all claims in the case and intends to vigorously defend itself against these claims.

Related Party Transactions

Related Party Transactions	12 Months Ended
	Dec. 31, 2022
Related Party Transactions [Abstract]
Related Party Transactions	Related Party Transactions As a result of the closing of the 2016 Transaction with Ascension Health Alliance on February 16, 2016 and Ascension Health Alliance’s ownership interest in TCP-ASC, 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, Description of Business, and Note 16, 8.00% Series A Convertible Preferred Stock, for further discussion about the agreements with Ascension. In conjunction with the Cloudmed Acquisition, New Mountain became a new related party. There were no material transactions with New Mountain subsequent to the Cloudmed Acquisition. Net services revenue from services provided to Ascension, as well as corresponding accounts receivable and customer liabilities are presented in the Consolidated Statements of Operations and Comprehensive Income (Loss) and the Consolidated Balance Sheets. Customer liabilities for Ascension consist of the following: December 31, 2022 December 31, 2021 Accrued service costs, current $ 4.3 $ 4.2 Collections payable to clients, current 0.3 0.6 Refund liabilities, current 0.7 0.6 Deferred revenue (contract liabilities), current 2.1 2.5 Current portion of customer liabilities 7.4 7.9 Deferred revenue (contract liabilities), non-current 13.7 15.4 Non-current portion of customer liabilities 13.7 15.4 Total customer liabilities $ 21.1 $ 23.3 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. On May 27, 2021 and May 28, 2021, the Company issued 16,750,000 shares of common stock to TCP-ASC upon the cashless exercise of a portion of the Warrant to purchase 19,535,145 shares of common stock at an exercise price of $3.50 per share based upon a market value of $24.54 to $24.64 per share as determined under the terms of the Warrant.

Segments and Customer Concentra

Segments and Customer Concentrations	12 Months Ended
	Dec. 31, 2022
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 the way that management operates and views the business. All of the Company’s significant operations are organized around the single business of providing management services of revenue cycle operations for U.S.-based healthcare providers. Accordingly, for purposes of segment disclosures, the Company has only one operating and reportable segment. Customers comprising greater than 10% of net services revenue are as follows: Year Ended December 31, Customer Name 2022 2021 2020 Ascension and its affiliates 49% 61% 64% Intermountain Healthcare 12% 14% 14% The loss of customers within the Ascension health system or Intermountain network would have a material adverse impact on the Company’s operations. As of December 31, 2022 and 2021, the Company had a concentration of credit risk with Ascension, representing 10% and 17% of accounts receivable, respectively. See Note 19, Related Party Transactions, for more information about the Company’s relationship with Ascension.

Retirement Plan

Retirement Plan	12 Months Ended
	Dec. 31, 2022
Retirement Benefits [Abstract]
Retirement Plan	Retirement Plan The Company maintains 401(k) retirement plans that are intended to be tax-qualified defined contribution plans under Section 401(k) of the Internal Revenue Code. In general, all employees are eligible to participate. In conjunction with acquisitions, the Company may integrate or maintain the acquiree’s 401(k) plan. For the years ended December 31, 2022, 2021, and 2020, Company contributions to the 401(k) plans were $13.3 million, $9.1 million, and $3.6 million, respectively.

Supplemental Financial Informat

Supplemental Financial Information	12 Months Ended
	Dec. 31, 2022
Deferred Costs, Capitalized, Prepaid, and Other Assets Disclosure [Abstract]
Supplemental Financial Information	Supplemental Financial Information Prepaid expenses and other current assets is comprised of the following: December 31, 2022 December 31, 2021 Prepaid expenses $ 35.1 $ 27.8 Acquisition and disposition contingent assets 20.0 29.1 Notes receivable 12.0 1.0 Derivative assets 8.8 1.7 Healthcare rebates receivable 5.9 4.5 Deferred contract costs 5.1 3.7 Other current assets 23.4 9.4 Total prepaid expenses and other current assets $ 110.3 $ 77.2 Accrued expenses and other current liabilities is comprised of the following: December 31, 2022 December 31, 2021 Accrued expenses $ 36.4 $ 33.8 Notes payable 15.5 8.3 Acquisition deferred payments 12.5 12.5 Other current liabilities 6.2 4.5 Total accrued expenses and other current liabilities $ 70.6 $ 59.1

Summary of Significant Accoun_2

Summary of Significant Accounting Policies (Policies)	12 Months Ended
	Dec. 31, 2022
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.
Revenue Recognition	Revenue Recognition The Company’s largest source of revenue is its operating partner arrangement to provide end-to-end RCM services. The Company also generates revenue through modular RCM solutions, where customers will engage the Company for only specific components of its end-to-end RCM service offering on a fixed-fee or volumetric basis. Revenue Cycle Management RCM services fees are primarily variable and performance related, and are generally viewed as a series of distinct services in which there are identifiable increments within a long-term service contract. 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 modular 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. Modular and Other The Company recognizes revenue related to modular and other RCM fees as RCM services are provided. Fees are typically variable in nature and revenue is recognized as services are provided or when any uncertainty associated with the variable fee is subsequently resolved. 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 upon request. 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 solutions 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 three 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. Revenue for the individual services is recognized ratably as services are performed, which is materially within the same accounting period for the services in the bundle. 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 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, rent, share-based compensation, amortization of intangible assets, assumed vendor contracts for onboarded customers, and other costs. Costs associated with generating the Company’s net services revenue are expensed as incurred, with the exception of deferred contract costs, which are certain costs associated with the initial phases of customer contracts and the related transition of customer hospitals and physician groups that are deferred. These fulfillment costs relate directly to the Company’s responsibilities under the corresponding customer contracts, generate or enhance resources of the Company that will be used in satisfying its performance obligations in the future, and are expected to be recovered through the margins realized. The following table summarizes the breakout of deferred contract costs: December 31, 2022 December 31, 2021 Prepaid expenses and other current assets $ 5.1 $ 3.7 Non-current portion of deferred contract costs 26.7 23.4 Total deferred contract costs $ 31.8 $ 27.1
Comprehensive Income	Comprehensive Income Comprehensive income is the net income of the Company combined with other changes in stockholders’ equity 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 Equivalents The Company considers all highly liquid investments with a maturity of three months or less when purchased to be cash equivalents.
Cloud Computing Arrangements	Cloud Computing Arrangements The Company capitalizes qualifying set-up and implementation costs related to the Company’s cloud computing arrangements. The deferred costs are amortized over the term of the associated cloud computing arrangement on a straight-line basis unless another systematic and rational basis is more representative of the pattern in which the Company expects to benefit from access to the cloud computing arrangement.
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. The Company capitalizes qualifying internal and third-party costs and hardware and software costs related to the Company’s software development activities. The Company amortizes the capitalized software development costs over their estimated life on a straight-line basis.
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.
Fair Value of Financial Instruments	Fair Value of Financial Instruments The 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, 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.
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.
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. As of December 31, 2022 and 2021, the Company had net assets of $81.5 million and $51.0 million in foreign entities, respectively. 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. For the year ended December 31, 2022, the number of options granted (24,344) was immaterial. As part of the transactions contemplated by the Transaction Agreement, equity awards held by certain employees of Cloudmed (“Former Class P Units”) were modified, through a series of transactions, into awards (“Management Units”) of CoyCo 2. Certain Former Class P Units that were subject to performance-based vesting conditions did not become vested upon the closing of the Cloudmed Acquisition (“Unvested Units”). The Management Units issued by CoyCo 2 are treated as share-based compensation under ASC 718, Compensation - Stock Compensation. The Unvested Units are not awards of the Company and the participants will receive no additional shares of the Company upon satisfaction of the vesting criteria described in Note 13, Share-Based Compensation. However, GAAP requires the Company recognize the cost of share-based compensation granted by an investor (CoyCo 2) to the Company’s employees and service providers for services that benefit the Company’s operations (hereafter, “CoyCo 2 share-based compensation expense”), and a corresponding capital contribution because the costs are incurred on the Company’s behalf. A Monte Carlo simulation was used to estimate the fair value of the Unvested Units. 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.
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 formerly but no longer in issue (as defined in Note 12) participates in dividends alongside the Company’s common stock (per their participating dividends), the preferred stock would constitute participating securities under ASC 260-10, Earnings Per Share, 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 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, 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 Disclosures In October 2021, the Financial Accounting Standards Board (“FASB”) issued Accounting Standards Update (“ASU”) 2021-08, Business Combinations (Topic 805): Accounting for Contract Assets and Contract Liabilities from Contracts with Customers (“ASU 2021-08”). ASU 2021-08 requires companies to apply Topic 606, Revenue from Contracts with Customers, to recognize and measure contract assets and contract liabilities obtained in a business combination. The ASU amendments will generally result in the recognition of contract assets and contract liabilities by the acquirer at amounts consistent with those recorded by the acquiree immediately before the acquisition date. The Company prospectively adopted ASU 2021-08 effective April 1, 2022 and preliminarily recognized contract assets of $92.4 million and contract liabilities of $3.3 million as part of the Cloudmed Acquisition. In June 2022, the FASB issued ASU 2022-03, Fair Value Measurement (Topic 820): Fair Value Measurement of Equity Securities Subject to Contractual Sale Restrictions (“ASU 2022-03”). ASU 2022-03 clarifies that a contractual sale restriction on an equity security should not be considered in measuring the security’s fair value. The Company will adopt ASU 2022-03 prospectively effective January 1, 2024 and is currently evaluating the impact of the standard on its consolidated financial statements.
Goodwill	GoodwillGoodwill represents the difference between the purchase price of acquired companies and the related fair value of the net assets acquired, which applies the acquisition method of accounting.
Derivative Financial Instruments	Derivative Financial Instruments The Company actively manages the risk of changes in foreign currency exchange rates and change in interest rates through non-deliverable 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. Positions are monitored using techniques such as market value and sensitivity analyses. The Company does not enter into derivative transactions for speculative purposes. 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 during the period in which the hedged transaction impacts earnings. 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.

Summary of Significant Accoun_3

Summary of Significant Accounting Policies (Tables)	12 Months Ended
	Dec. 31, 2022
Accounting Policies [Abstract]
Summary of Deferred Contract Costs	The following table summarizes the breakout of deferred contract costs: December 31, 2022 December 31, 2021 Prepaid expenses and other current assets $ 5.1 $ 3.7 Non-current portion of deferred contract costs 26.7 23.4 Total deferred contract costs $ 31.8 $ 27.1
Schedule of Property, Equipment and Software Useful Lives	The major classifications of property, equipment and software and their expected useful lives are as follows: Buildings and land 30 years and indefinite Computers and other equipment 3 years Leasehold improvements Shorter of 10 years or lease term Office furniture 5 years Software 3 to 5 years
Schedule of Property, Equipment and Software	Property, equipment and software consist of the following: December 31, 2022 December 31, 2021 Buildings and land $ 24.3 $ — Computer and other equipment 75.6 60.4 Leasehold improvements 24.1 23.3 Software 243.2 177.0 Office furniture 12.4 6.5 Property, equipment and software, gross 379.6 267.2 Less accumulated depreciation and amortization (214.8) (172.5) Property, equipment and software, net $ 164.8 $ 94.7
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: Year Ended December 31, 2022 2021 2020 Cost of services $ 53.4 $ 51.8 $ 46.6 Selling, general and administrative 1.2 2.8 4.0 Total depreciation and amortization $ 54.6 $ 54.6 $ 50.6

Acquisitions (Tables)

Acquisitions (Tables)	12 Months Ended
	Dec. 31, 2022
Business Combination and Asset Acquisition [Abstract]
Schedule of Acquisitions	The following table summarizes the fair value of the total consideration paid: Fair Value Stock consideration transferred to the Sellers (1) $ 2,390.5 Cash consideration (2) 879.8 Replacement awards issued to Cloudmed equity award holders (3) 11.3 Total consideration $ 3,281.6 (1) The stock consideration fair value includes a 12.5% discount for lack of marketability factor related to an 18-month lock-up period during which the Sellers may not sell their Company common stock. (2) Cash consideration includes the repayment of Cloudmed’s pre-existing credit facility that was paid off at closing and was not assumed by the Company. During 2021, the Company acquired the following business: Company Name Description of the Business Description of the Acquisition iVinci Partners, LLC d/b/a VisitPay (“VisitPay”) Provider of digital payment solutions Purchased all outstanding equity interests
Schedule of Fair Value of Assets Acquired and Liabilities Assumed	The preliminary fair value of assets acquired and liabilities assumed is: Purchase Price Allocation Total purchase consideration $ 3,281.6 Allocation of consideration to assets acquired and liabilities assumed: Cash and cash equivalents $ 32.1 Accounts receivable 61.8 Current portion of contract assets 68.5 Property, equipment and software 5.0 Operating lease right-of-use assets 25.3 Non-current portion of contract assets 23.9 Intangible assets 1,366.6 Goodwill 2,103.6 Other assets 6.7 Accounts payable (31.9) Customer liabilities (3.3) Accrued compensation and benefits (93.0) Operating lease liabilities (25.4) Deferred income tax liabilities (245.4) Other liabilities (12.9) Net assets acquired $ 3,281.6
Schedule of Intangible Assets Identified with Acquisition	The intangible assets identified in conjunction with the Cloudmed Acquisition and their preliminary fair values are as follows: Useful Life Gross Carrying Value Customer Relationships 18 years $ 318.0 Technology 7 years $ 1,025.0 Tradename 5 years $ 23.5 Favorable leasehold interests Life of lease $ 0.1 The following table provides the gross carrying value and accumulated amortization for each major class of definite-lived intangible assets at December 31, 2022 and December 31, 2021: December 31, 2022 December 31, 2021 Gross Carrying Value Accumulated Amortization Net Book Value Gross Carrying Value Accumulated Amortization Net Book Value Customer relationships $ 418.0 $ (36.3) $ 381.7 $ 100.0 $ (20.8) $ 79.2 Technology 1,240.5 (129.3) 1,111.2 215.5 (30.2) 185.3 Tradename 24.5 (3.0) 21.5 1.0 (0.1) 0.9 Favorable leasehold interests 0.1 — 0.1 — — — Total intangible assets $ 1,683.1 $ (168.6) $ 1,514.5 $ 316.5 $ (51.1) $ 265.4
Schedule of Pro Forma Results	The following table summarizes, on a pro forma basis, the combined results of the Company as though the Cloudmed Acquisition had occurred as of January 1, 2021 and the VisitPay acquisition had occurred as of January 1, 2020. These pro forma results are not necessarily indicative of the actual consolidated results had the acquisitions occurred as of those dates or of the future consolidated operating results for any period. Pro forma results are: Year Ended December 31, 2022 2021 Net services revenue $ 2,009.7 $ 1,813.5 Net loss $ (55.0) $ (177.5)

Intangible Assets (Tables)

Intangible Assets (Tables)	12 Months Ended
	Dec. 31, 2022
Goodwill and Intangible Assets Disclosure [Abstract]
Schedule of Intangible Assets	The intangible assets identified in conjunction with the Cloudmed Acquisition and their preliminary fair values are as follows: Useful Life Gross Carrying Value Customer Relationships 18 years $ 318.0 Technology 7 years $ 1,025.0 Tradename 5 years $ 23.5 Favorable leasehold interests Life of lease $ 0.1 The following table provides the gross carrying value and accumulated amortization for each major class of definite-lived intangible assets at December 31, 2022 and December 31, 2021: December 31, 2022 December 31, 2021 Gross Carrying Value Accumulated Amortization Net Book Value Gross Carrying Value Accumulated Amortization Net Book Value Customer relationships $ 418.0 $ (36.3) $ 381.7 $ 100.0 $ (20.8) $ 79.2 Technology 1,240.5 (129.3) 1,111.2 215.5 (30.2) 185.3 Tradename 24.5 (3.0) 21.5 1.0 (0.1) 0.9 Favorable leasehold interests 0.1 — 0.1 — — — Total intangible assets $ 1,683.1 $ (168.6) $ 1,514.5 $ 316.5 $ (51.1) $ 265.4
Schedule of Estimated Annual Amortization Expense	Estimated annual amortization expense related to intangible assets with definite lives as of December 31, 2022 is as follows: 2023 $ 197.2 2024 195.3 2025 193.7 2026 193.7 2027 191.2 Thereafter 543.4 Total $ 1,514.5

Goodwill (Tables)

Goodwill (Tables)	12 Months Ended
	Dec. 31, 2022
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, 2022 were: Goodwill Balance as of December 31, 2021 $ 554.7 Cloudmed Acquisition 2,103.6 Change in foreign currency rates (0.1) Balance as of December 31, 2022 $ 2,658.2

Revenue Recognition (Tables)

Revenue Recognition (Tables)	12 Months Ended
	Dec. 31, 2022
Revenue from Contract with Customer [Abstract]
Schedule of Disaggregated Revenue By Source	In the following table, revenue is disaggregated by source of revenue: Year Ended December 31, 2022 2021 2020 Net operating fees $ 1,309.7 $ 1,211.8 $ 1,093.8 Incentive fees 106.8 143.8 70.6 Modular and other (1) 389.9 119.0 106.4 Net services revenue $ 1,806.4 $ 1,474.6 $ 1,270.8
Schedule of Contract Assets, Net and Contract Liabilities	The following table provides information about contract assets, net and contract liabilities from contracts with customers: December 31, 2022 December 31, 2021 Contract assets, net Current $ 83.9 $ — Non-current 32.0 — Total contract assets, net $ 115.9 $ — Contract liabilities Current (1) $ 9.7 $ 10.3 Non-current (2) 18.7 18.7 Total contract liabilities $ 28.4 $ 29.0 (1) Current contract liabilities include $7.6 million and $7.8 million classified in the current portion of customer liabilities and $2.1 million and $2.5 million classified in the current portion of customer liabilities - related party as of December 31, 2022 and 2021, respectively. Contract Assets Balance as of June 30, 2022 $ 89.6 Revenue recognized 172.9 Amounts billed (151.0) Other (1) 4.4 Balance as of December 31, 2022 $ 115.9 (1) Other primarily includes measurement period adjustments to the contract assets acquired from the Cloudmed Acquisition.
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. The estimated revenue does not include amounts of variable consideration that are constrained. Net operating fees Incentive fees 2023 $ 115.4 $ 27.0 2024 82.5 — 2025 39.3 — 2026 38.2 — 2027 34.1 — Thereafter 124.9 — Total $ 434.4 $ 27.0

Accounts Receivable and Allow_2

Accounts Receivable and Allowance for Credit Losses (Tables)	12 Months Ended
	Dec. 31, 2022
Receivables [Abstract]
Schedule of Allowance for Credit Losses Related to Accounts Receivable	Movements in the allowance for credit losses related to accounts receivable are as follows: Year Ended December 31, 2022 2021 Beginning balance $ 2.5 $ 3.8 Cumulative effect of Cloudmed ASC 326 adoption 1.8 — Provision (recoveries) 11.1 0.7 Write-offs (0.2) (2.0) Ending balance $ 15.2 $ 2.5

Leases (Tables)

Leases (Tables)	12 Months Ended
	Dec. 31, 2022
Leases [Abstract]
Schedules of Components of Lease Costs and Supplemental Information Related to Operating Leases	The components of lease costs are as follows: Year Ended December 31, 2022 2021 Operating lease cost $ 22.1 $ 15.8 Sublease income (1.6) (2.3) Total lease cost $ 20.5 $ 13.5 The following table summarizes the supplemental information related to operating leases: Year Ended December 31, 2022 2021 Weighted average remaining lease term 7 years 7 years Weighted average incremental borrowing rate 6.52 % 8.10 % Cash paid for amounts included in the measurement of lease liabilities: Operating cash flows for operating leases $ 27.0 $ 22.8 ROU assets obtained or acquired in exchange for operating lease obligations (1) 67.7 20.3
Schedule of Operating Lease Maturity	Maturities of lease liabilities as of December 31, 2022 are as follows: Operating Leases 2023 $ 24.6 2024 23.9 2025 22.6 2026 16.8 2027 10.7 Thereafter 40.7 Total 139.3 Less: Imputed interest 26.9 Present value of lease liabilities $ 112.4

Customer Liabilities (Tables)

Customer Liabilities (Tables)	12 Months Ended
	Dec. 31, 2022
Other Liabilities Disclosure [Abstract]
Schedule of Customer Liabilities	Customer liabilities consist of the following: December 31, 2022 December 31, 2021 Accrued service costs, current $ 21.9 $ 32.3 Collections payable to clients, current 29.1 3.0 Customer deposits, current 1.5 — Refund liabilities, current 2.7 3.8 Deferred revenue (contract liabilities), current 9.7 10.3 Current portion of customer liabilities (1) 64.9 49.4 Deferred revenue (contract liabilities), non-current 18.7 18.7 Non-current portion of customer liabilities (1) 18.7 18.7 Total customer liabilities $ 83.6 $ 68.1 (1) Current and non-current portion of customer liabilities include amounts for a related party. See Note 19, Related Party Transactions, for further discussion.

Debt (Tables)

Debt (Tables)	12 Months Ended
	Dec. 31, 2022
Debt Disclosure [Abstract]
Schedule of Carrying Values Long-Term Debt	The carrying amounts of debt consist of the following: December 31, 2022 December 31, 2021 Senior Revolver (1) $ 100.0 $ 80.0 Term A Loans 1,211.4 695.6 Term B Loan 498.7 — Unamortized discount and issuance costs (23.6) (3.2) Total debt 1,786.5 772.4 Less: Current maturities (53.9) (17.5) Total long-term debt $ 1,732.6 $ 754.9 (1) As of December 31, 2022, the Company had $100.0 million in borrowings, $0.9 million letters of credit outstanding, and $499.1 million of availability under the senior secured revolving credit facility (“Senior Revolver”).
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, 2022 and thereafter are summarized as follows: Scheduled Maturities 2023 $ 53.9 2024 67.0 2025 67.0 2026 718.3 2027 430.2 Thereafter 473.7 Total $ 1,810.1

Derivative Financial Instrume_2

Derivative Financial Instruments (Tables)	12 Months Ended
	Dec. 31, 2022
Derivative Instruments and Hedging Activities Disclosure [Abstract]
Schedule of Derivatives Instruments Statements of Financial Performance and Financial Position, Location	The location and fair value of derivative instruments designated as hedges in the Consolidated Balance Sheets as of December 31, 2022 and December 31, 2021 are as follows: December 31, 2022 December 31, 2021 Foreign currency forward contracts Prepaid expenses and other current assets $ 0.1 $ 1.7 Other accrued expenses 0.5 — Total foreign current forward contracts $ 0.6 $ 1.7 Interest rate swaps Prepaid expenses and other current assets $ 8.7 $ — Other assets 5.0 — Other accrued expenses — 0.7 Total interest rate swaps $ 13.7 $ 0.7

Share-Based Compensation (Table

Share-Based Compensation (Tables)	12 Months Ended
	Dec. 31, 2022
Share-Based Payment Arrangement [Abstract]
Summary of Valuation Assumptions	The following table sets forth the significant assumptions used in the calculation of share-based compensation expense during 2022, 2021, and 2020: Year Ended December 31, 2022 2021 2020 Expected dividend yield —% —% —% Risk-free interest rate 1.4% to 3.3% 0.4% to 1.0% 0.3% to 1.7% Expected volatility 43% to 50% 43% 43% Expected term (in years) 4.0 to 5.5 5.5 5.5
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: Year Ended December 31, 2022 2021 2020 Share-Based Compensation Expense Allocation Details: Cost of services $ 28.8 $ 44.2 $ 9.9 Selling, general and administrative 38.2 30.1 14.1 Other 0.1 — 0.1 Total share-based compensation expense (1) $ 67.1 $ 74.3 $ 24.1 (1) Included in the share-based compensation expense above is $5.1 million of CoyCo 2 share-based compensation expense for the year ended December 31, 2022. See further discussion below. In addition to the share-based compensation expense recorded above, $0.3 million , $0.6 million, and $0.1 million of share-based compensation expense was capitalized to deferred contract costs for the years ended December 31, 2022 ,
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, 2022, 2021, and 2020: Shares Weighted- Weighted- Aggregate Outstanding at January 1, 2020 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 Granted 6,424 23.33 Exercised (1,819,039) 4.39 Canceled/forfeited (15,151) 5.98 Expired (7,000) 27.08 Outstanding at December 31, 2021 4,386,205 $ 3.37 4.9 $ 97.0 Granted 24,344 22.19 Exercised (1,285,228) 3.67 Canceled/forfeited (13,408) 4.59 Expired (7,500) 8.71 Outstanding at December 31, 2022 3,104,413 $ 3.38 4.0 $ 23.9 Outstanding, vested and exercisable at December 31, 2020 5,230,690 $ 3.73 5.5 $ 106.2 Outstanding, vested and exercisable at December 31, 2021 4,365,759 $ 3.33 4.9 $ 96.7 Outstanding, vested and exercisable at December 31, 2022 3,080,069 $ 3.23 4.0 $ 23.9
Schedule of Restricted Stock Units and Performance-based Restricted Stock Units Activity	The following table sets forth a summary of all RSU and PBRSU activity during the years ended December 31, 2022, 2021, and 2020: Weighted- RSUs PBRSUs RSU PBRSU Outstanding and unvested at January 1, 2020 1,373,356 4,119,436 $ 8.03 $ 6.37 Granted 1,588,120 1,637,581 10.29 13.25 Performance factor adjustment — 3,879,186 — 14.72 Vested (504,708) (6,344,151) 6.74 13.11 Forfeited (348,321) (374,981) 9.09 6.66 Outstanding and unvested at December 31, 2020 2,108,447 2,917,071 $ 9.87 $ 11.35 Granted 2,251,167 1,071,431 24.35 25.36 Performance factor adjustment — 101,937 — 9.81 Vested (1,739,847) (586,071) 19.14 7.67 Forfeited (401,116) (301,355) 15.48 13.55 Outstanding and unvested at December 31, 2021 2,218,651 3,203,013 $ 16.28 $ 16.45 Granted 2,306,897 5,230,483 20.56 19.83 Performance factor adjustment — 876,109 — 10.46 Vested (1,029,491) (1,925,203) 16.61 11.05 Forfeited (264,055) (507,605) 18.22 20.38 Outstanding and unvested at December 31, 2022 3,232,002 6,876,797 $ 19.07 $ 19.48 Shares surrendered for taxes for year ended December 31, 2022 369,900 804,854 Cost of shares surrendered for taxes for the year ended December 31, 2022 (in millions) 7.4 20.2 Shares surrendered for taxes for the year ended December 31, 2021 571,182 225,726 Cost of shares surrendered for taxes for the year ended December 31, 2021 (in millions) 13.5 5.6 Shares surrendered for taxes for the year ended December 31, 2020 141,331 2,740,924 Cost of shares surrendered for taxes for the year ended December 31, 2020 (in millions) 1.4 64.2

Other Expenses (Tables)

Other Expenses (Tables)	12 Months Ended
	Dec. 31, 2022
Other Income and Expenses [Abstract]
Schedule of Other Expenses	The following table summarizes the other expenses (income) recognized for the years ended December 31, 2022, 2021, and 2020: Year Ended December 31, 2022 2021 2020 Severance and related employee benefits (1) $ 1.2 $ 2.2 $ 6.4 Business acquisition costs (2) 74.5 4.0 16.7 Integration costs (3) 40.2 2.6 5.4 Strategic initiatives (4) 23.2 9.1 7.2 Global business services center expansion project in the Philippines (5) 26.7 1.8 — Customer employee transition and restructuring expenses (6) (0.4) 4.9 (0.2) Facility-exit charges (7) 7.9 3.4 17.5 Other (8) 10.2 18.1 14.3 Total other expenses $ 183.5 $ 46.1 $ 67.3 (1) These costs relate to restructuring and business reorganization events. (2) These are costs, including legal, consulting, and bank fees, that are directly related to the closing of business acquisitions and include changes to contingent consideration. (3) These costs reflect efforts to integrate acquisitions from a systems, processes, and people perspective and to achieve synergies expected from the transaction. Costs include consulting fees, IT vendor spend, severance, early lease termination of Cloudmed facilities, and certain payroll costs. (4) These costs relate to performing portfolio and capital structure analyses and transactions and other business transformation projects (including large scale system projects) as part of the Company’s growth strategy. Costs include vendor spend, employee time and expenses spent on activities, severance, and retention amounts. (5) These costs include legal and consulting fees related to the establishment of the Company’s inaugural global business services center in the Philippines as well as severance costs for personnel whose roles are being relocated. The entry into the Philippines is the first new organic global business services center country expansion by the Company in approximately 15 years. (6) As part of the transition of customer personnel to the Company under certain operating partner model contracts, the Company agreed to reimburse the customer, or directly pay affected employees, for severance and retention costs related to certain employees who were not transitioned to the Company, or whose jobs were relocated after the employee transitioned to the Company. (7) As part of evaluating its footprint, the Company has exited certain leased facilities. Costs include asset impairment charges, early termination fees, and other costs related to exited leased facilities (excluding early lease termination of Cloudmed facilities, which is included in (3) above). (8) For the years ended December 31, 2022, 2021, and 2020, other includes $2.5 million, $11.3 million, and $10.9 million, respectively, of expenses related to the COVID-19 pandemic.

Income Taxes (Tables)

Income Taxes (Tables)	12 Months Ended
	Dec. 31, 2022
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: Year Ended December 31, 2022 2021 2020 Domestic $ (81.0) $ 110.1 $ 99.4 Foreign 20.0 16.7 19.0 Total income (loss) before income taxes $ (61.0) $ 126.8 $ 118.4
Schedule of Current and Deferred Income Tax Expense (Benefit)	For the years ended December 31, 2022, 2021, and 2020, the Company’s current and deferred income tax expense (benefit) attributable to income from operations are as follows: Current Deferred Total 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 Year Ended December 31, 2021 U.S. Federal $ (0.1) $ 21.7 $ 21.6 State & Local 3.4 — 3.4 Foreign 3.0 1.6 4.6 $ 6.3 $ 23.3 $ 29.6 Year Ended December 31, 2022 U.S. Federal $ 0.9 $ (11.5) $ (10.6) State & Local 3.9 (5.0) (1.1) Foreign 3.2 5.1 8.3 $ 8.0 $ (11.4) $ (3.4)
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, 2022 2021 2020 Federal statutory tax rate 21 % 21 % 21 % Change in income tax rate resulting from: State and local income taxes, net of federal tax benefits 1 % 2 % 1 % Additional tax on foreign source income (12) % 3 % 3 % Share-based compensation 20 % (8) % (24) % Non-deductible expenses (23) % 5 % 13 % Gain on sale — % — % (11) % Other (1) % — % (2) % Effective tax rate 6 % 23 % 1 %
Schedule of Net Deferred Tax	The following table sets forth the Company’s net deferred tax as of December 31, 2022 and 2021: As of December 31, 2022 2021 Deferred tax assets and liabilities: Net operating loss carryforwards $ 50.0 $ 54.7 Share-based compensation 16.6 12.2 Accrued bonus 13.7 8.5 Advanced billing revenue 6.8 7.2 Alternative minimum tax 6.2 6.4 Interest expense limitation 11.1 0.1 Deferred rent liabilities 29.1 19.3 Deferred FICA liability — 3.0 Fixed assets 1.0 — Other 13.1 12.3 Total deferred tax assets 147.6 123.7 Intangible assets (292.6) (41.7) Fixed assets — (1.5) Deferred contract costs (8.0) (8.7) Foreign withholding tax (10.2) (4.2) Deferred rent assets (20.0) (13.6) Less valuation allowances (7.1) (6.4) Net deferred tax $ (190.3) $ 47.6

8.00% Series A Convertible Pr_2

8.00% Series A Convertible Preferred Stock (Tables)	12 Months Ended
	Dec. 31, 2022
Temporary Equity Disclosure [Abstract]
Summary of Preferred Stock Activity	The following summarizes the Preferred Stock activity for the years ended December 31, 2021 and 2020: Preferred Stock Shares Issued and Outstanding Carrying Value Balance at January 1, 2020 266,529 $ 229.1 Dividends paid/accrued dividends 21,968 22.4 Balance at December 31, 2020 288,497 $ 251.5 Dividends paid/accrued dividends 5,769 — Conversion of Preferred Stock (294,266) (251.5) Balance at December 31, 2021 — $ —

Earnings (Loss) Per Share (Tabl

Earnings (Loss) Per Share (Tables)	12 Months Ended
	Dec. 31, 2022
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: Year Ended December 31, 2022 2021 2020 Basic EPS: Net income (loss) $ (57.6) $ 97.2 $ 117.1 Less dividends on preferred shares (1) — (592.3) (22.4) Less income allocated to preferred shareholders — — (47.3) Net income (loss) available/(allocated) to common shareholders - basic $ (57.6) $ (495.1) $ 47.4 Diluted EPS: Net income (loss) $ (57.6) $ 97.2 $ 117.1 Less dividends on preferred shares (1) — (592.3) (22.4) Less income allocated to preferred shareholders — — (37.7) Net income (loss) available/(allocated) to common shareholders - diluted $ (57.6) $ (495.1) $ 57.0 Basic weighted-average common shares 352,337,767 266,183,565 115,729,645 Add: Effect of dilutive equity awards — — 12,731,424 Add: Effect of dilutive warrants — — 46,112,201 Diluted weighted average common shares 352,337,767 266,183,565 174,573,270 Net income (loss) per common share (basic) $ (0.16) $ (1.86) $ 0.41 Net income (loss) per common share (diluted) $ (0.16) $ (1.86) $ 0.33 (1) The 2021 dividend on preferred shares includes amounts related to the conversion of the preferred shares. See Note 16, 8.00% Series A Convertible Preferred Stock, for more information.

Related Party Transactions (Tab

Related Party Transactions (Tables)	12 Months Ended
	Dec. 31, 2022
Related Party Transactions [Abstract]
Schedule of Related Party Transactions	Net services revenue from services provided to Ascension, as well as corresponding accounts receivable and customer liabilities are presented in the Consolidated Statements of Operations and Comprehensive Income (Loss) and the Consolidated Balance Sheets. Customer liabilities for Ascension consist of the following: December 31, 2022 December 31, 2021 Accrued service costs, current $ 4.3 $ 4.2 Collections payable to clients, current 0.3 0.6 Refund liabilities, current 0.7 0.6 Deferred revenue (contract liabilities), current 2.1 2.5 Current portion of customer liabilities 7.4 7.9 Deferred revenue (contract liabilities), non-current 13.7 15.4 Non-current portion of customer liabilities 13.7 15.4 Total customer liabilities $ 21.1 $ 23.3

Segments and Customer Concent_2

Segments and Customer Concentrations (Tables)	12 Months Ended
	Dec. 31, 2022
Segment Reporting [Abstract]
Schedule of Customer Concentration, Net Services Revenue	Customers comprising greater than 10% of net services revenue are as follows: Year Ended December 31, Customer Name 2022 2021 2020 Ascension and its affiliates 49% 61% 64% Intermountain Healthcare 12% 14% 14%

Supplemental Financial Inform_2

Supplemental Financial Information (Tables)	12 Months Ended
	Dec. 31, 2022
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: December 31, 2022 December 31, 2021 Prepaid expenses $ 35.1 $ 27.8 Acquisition and disposition contingent assets 20.0 29.1 Notes receivable 12.0 1.0 Derivative assets 8.8 1.7 Healthcare rebates receivable 5.9 4.5 Deferred contract costs 5.1 3.7 Other current assets 23.4 9.4 Total prepaid expenses and other current assets $ 110.3 $ 77.2
Schedule of Accrued Expenses and Other Current Liabilities	Accrued expenses and other current liabilities is comprised of the following: December 31, 2022 December 31, 2021 Accrued expenses $ 36.4 $ 33.8 Notes payable 15.5 8.3 Acquisition deferred payments 12.5 12.5 Other current liabilities 6.2 4.5 Total accrued expenses and other current liabilities $ 70.6 $ 59.1

Description of Business - Narra

Description of Business - Narrative (Details) - USD ($) $ in Millions				1 Months Ended	12 Months Ended
	Jun. 21, 2022	Oct. 30, 2020	Feb. 16, 2016	Oct. 31, 2022	Dec. 31, 2022	Dec. 31, 2021	Dec. 31, 2020
Income Statement, Balance Sheet and Additional Disclosures by Disposal Groups, Including Discontinued Operations [Line Items]
Long term strategic partnership, term			10 years
Gain on business disposition					$ 0	$ 0	$ 55.7
Cloudmed
Income Statement, Balance Sheet and Additional Disclosures by Disposal Groups, Including Discontinued Operations [Line Items]
Percentage of business acquired	100%
Acquisition, aggregate number of shares of common stock issued (in shares)	135,929,742			55,846
Disposal Group, Disposed of by Sale, Not Discontinued Operations | EMS Disposition
Income Statement, Balance Sheet and Additional Disclosures by Disposal Groups, Including Discontinued Operations [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
Gain on business disposition		$ 55.7

Summary of Significant Accoun_4

Summary of Significant Accounting Policies - Narrative (Details)	12 Months Ended
	Dec. 31, 2022 USD ($) payment shares	Dec. 31, 2021 USD ($) shares	Dec. 31, 2020 USD ($) shares	Jun. 30, 2022 USD ($)	Apr. 01, 2022 USD ($)
Revenue from External Customer [Line Items]
Base fees, number of monthly payments | payment	3
Contract amortization	$ 8,300,000	$ 4,600,000
Impairment losses	0	0
Net capitalized cloud computing implementation costs	6,800,000	8,600,000
Impairment of property, equipment, software, deferred contract costs, or other intangible assets	$ 0	$ 0	$ 0
Granted (in shares) | shares	24,344	6,424	80,425
Contract assets	$ 115,900,000	$ 0		$ 89,600,000
Accounting Standards Update 2021-08 | Cloudmed
Revenue from External Customer [Line Items]
Contract assets					$ 92,400,000
Contract liabilities					$ 3,300,000
Foreign Entities
Revenue from External Customer [Line Items]
Net assets	81,500,000	51,000,000
Fair Value, Measurements, Recurring
Revenue from External Customer [Line Items]
Financial liabilities required to be measured at fair value	0
Financial assets required to be measured at fair value	0
Located Internationally
Revenue from External Customer [Line Items]
Property, equipment and software, net	$ 20,300,000	$ 13,900,000
Minimum | End-To-End Services
Revenue from External Customer [Line Items]
Revenue, contract term	3 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 - Summary of Deferred Contract Costs (Details) - USD ($) $ in Millions	Dec. 31, 2022	Dec. 31, 2021
Capitalized Contract Cost [Line Items]
Prepaid expenses and other current assets	$ 5.1	$ 3.7
Non-current portion of deferred contract costs	26.7	23.4
Total deferred contract costs	31.8	27.1
Prepaid expenses and other current assets
Capitalized Contract Cost [Line Items]
Prepaid expenses and other current assets	5.1	3.7
Non-current portion of deferred contract costs
Capitalized Contract Cost [Line Items]
Non-current portion of deferred contract costs	$ 26.7	$ 23.4

Summary of Significant Accoun_6

Summary of Significant Accounting Policies - Property, Equipment and Software Useful Lives (Details)	12 Months Ended
	Dec. 31, 2022
Buildings and land
Property, Plant and Equipment [Line Items]
Useful lives	30 years
Computers and other equipment
Property, Plant and Equipment [Line Items]
Useful lives	3 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

Summary of Significant Accoun_7

Summary of Significant Accounting Policies - Schedule of Property, Equipment and Software (Details) - USD ($) $ in Millions	Dec. 31, 2022	Dec. 31, 2021
Property, Plant and Equipment [Line Items]
Property, equipment and software, gross	$ 379.6	$ 267.2
Less accumulated depreciation and amortization	(214.8)	(172.5)
Property, equipment and software, net	164.8	94.7
Buildings and land
Property, Plant and Equipment [Line Items]
Property, equipment and software, gross	24.3	0
Computer and other equipment
Property, Plant and Equipment [Line Items]
Property, equipment and software, gross	75.6	60.4
Leasehold improvements
Property, Plant and Equipment [Line Items]
Property, equipment and software, gross	24.1	23.3
Software
Property, Plant and Equipment [Line Items]
Property, equipment and software, gross	243.2	177
Office furniture
Property, Plant and Equipment [Line Items]
Property, equipment and software, gross	$ 12.4	$ 6.5

Summary of Significant Accoun_8

Summary of Significant Accounting Policies - 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, 2022	Dec. 31, 2021	Dec. 31, 2020
Property, Plant and Equipment [Line Items]
Total depreciation and amortization	$ 54.6	$ 54.6	$ 50.6
Cost of services
Property, Plant and Equipment [Line Items]
Total depreciation and amortization	53.4	51.8	46.6
Selling, general and administrative
Property, Plant and Equipment [Line Items]
Total depreciation and amortization	$ 1.2	$ 2.8	$ 4

Acquisitions - Narrative (Detai

Acquisitions - Narrative (Details) $ in Millions		1 Months Ended		3 Months Ended		12 Months Ended
	Jun. 21, 2022 USD ($)	Aug. 31, 2022 USD ($)	Aug. 31, 2020 payment	Dec. 31, 2022 USD ($)	Sep. 30, 2021 USD ($)	Dec. 31, 2022 USD ($)	Dec. 31, 2021 USD ($)	Dec. 31, 2020 USD ($)
Business Acquisition [Line Items]
Increase to intangible assets				$ (3.5)
Increase to the deferred income tax liability				$ 103.4
Payments to acquire business						$ 0	$ 12.5	$ 0
Cloudmed
Business Acquisition [Line Items]
Purchase price	$ 3,300
Net sales						260
Net loss, before income taxes, since acquisition date						$ 10.7
RevWorks
Business Acquisition [Line Items]
Payments to acquire business		$ 12.5			$ 12.5
Number of deferred payments | payment			2
Payments to acquire business, number of payments, refund period, if circumstances met			2 years

Acquisitions - Fair Value Total

Acquisitions - Fair Value Total Consideration Paid (Details) - Cloudmed $ in Millions	Jun. 21, 2022 USD ($) shares
Business Acquisition [Line Items]
Stock consideration transferred to the Sellers	$ 2,390.5
Cash consideration	879.8
Total purchase consideration	$ 3,281.6
Stock consideration fair value discount percent	12.50%
Cloudmed
Business Acquisition [Line Items]
Lock-up period	18 months
Restricted Stock Units (RSUs)
Business Acquisition [Line Items]
Replacement awards issued to Cloudmed equity award holders	$ 11.3
Replacement awards issued to Cloudmed equity award holders, shares (in shares) | shares	1,536,220

Acquisitions - Fair Value of As

Acquisitions - Fair Value of Assets Acquired and Liabilities Assumed (Details) - USD ($) $ in Millions	Jun. 21, 2022	Dec. 31, 2022	Dec. 31, 2021
Allocation of consideration to assets acquired and liabilities assumed:
Goodwill		$ 2,658.2	$ 554.7
Cloudmed
Business Acquisition [Line Items]
Total purchase consideration	$ 3,281.6
Allocation of consideration to assets acquired and liabilities assumed:
Cash and cash equivalents	32.1
Accounts receivable	61.8
Current portion of contract assets	68.5
Property, equipment and software	5
Operating lease right-of-use assets	25.3
Non-current portion of contract assets	23.9
Intangible assets	1,366.6
Goodwill	2,103.6
Other assets	6.7
Accounts payable	(31.9)
Customer liabilities	(3.3)
Accrued compensation and benefits	(93)
Operating lease liabilities	(25.4)
Deferred income tax liabilities	(245.4)
Other liabilities	(12.9)
Net assets acquired	$ 3,281.6

Acquisitions - Schedule of Inta

Acquisitions - Schedule of Intangible Assets Information (Details) - Cloudmed $ in Millions	Jun. 21, 2022 USD ($)
Customer Relationships
Business Acquisition [Line Items]
Useful Life	18 years
Gross Carrying Value	$ 318
Technology
Business Acquisition [Line Items]
Useful Life	7 years
Gross Carrying Value	$ 1,025
Tradename
Business Acquisition [Line Items]
Useful Life	5 years
Gross Carrying Value	$ 23.5
Favorable leasehold interests
Business Acquisition [Line Items]
Gross Carrying Value	$ 0.1

Acquisitions - Pro Forma Result

Acquisitions - Pro Forma Results (Details) - Cloudmed Acquisition and VisitPay Acquisition - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2022	Dec. 31, 2021
Business Acquisition [Line Items]
Net services revenue	$ 2,009.7	$ 1,813.5
Net loss	$ (55)	$ (177.5)

Intangible Assets - Components

Intangible Assets - Components of Intangible Assets (Details) - USD ($) $ in Millions	Dec. 31, 2022	Dec. 31, 2021
Finite-Lived Intangible Assets [Line Items]
Gross Carrying Value	$ 1,683.1	$ 316.5
Accumulated Amortization	(168.6)	(51.1)
Net Book Value	1,514.5	265.4
Customer relationships
Finite-Lived Intangible Assets [Line Items]
Gross Carrying Value	418	100
Accumulated Amortization	(36.3)	(20.8)
Net Book Value	381.7	79.2
Technology
Finite-Lived Intangible Assets [Line Items]
Gross Carrying Value	1,240.5	215.5
Accumulated Amortization	(129.3)	(30.2)
Net Book Value	1,111.2	185.3
Tradename
Finite-Lived Intangible Assets [Line Items]
Gross Carrying Value	24.5	1
Accumulated Amortization	(3)	(0.1)
Net Book Value	21.5	0.9
Favorable leasehold interests
Finite-Lived Intangible Assets [Line Items]
Gross Carrying Value	0.1	0
Accumulated Amortization	0	0
Net Book Value	$ 0.1	$ 0

Intangible Assets - Narrative (

Intangible Assets - Narrative (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2022	Dec. 31, 2021	Dec. 31, 2020
Goodwill and Intangible Assets Disclosure [Abstract]
Intangible asset amortization expense	$ 117.4	$ 22.9	$ 18.1

Intangible Assets - Future Amor

Intangible Assets - Future Amortization (Details) - USD ($) $ in Millions	Dec. 31, 2022	Dec. 31, 2021
Finite-Lived Intangible Assets, Amortization Expense, Maturity Schedule [Abstract]
2023	$ 197.2
2024	195.3
2025	193.7
2026	193.7
2027	191.2
Thereafter	543.4
Net Book Value	$ 1,514.5	$ 265.4

Goodwill - Carrying Amount of G

Goodwill - Carrying Amount of Goodwill (Details) $ in Millions	12 Months Ended
	Dec. 31, 2022 USD ($)
Goodwill [Roll Forward]
Beginning Balance	$ 554.7
Cloudmed Acquisition	2,103.6
Change in foreign currency rates	(0.1)
Ending Balance	$ 2,658.2

Goodwill - Narrative (Details)

Goodwill - Narrative (Details)	12 Months Ended
	Dec. 31, 2022 USD ($) reporting_unit
Goodwill and Intangible Assets Disclosure [Abstract]
Number of reporting units | reporting_unit	1
Impairment of goodwill | $	$ 0

Revenue Recognition - Schedule

Revenue Recognition - Schedule of Disaggregated Revenue by Source (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2022	Dec. 31, 2021	Dec. 31, 2020
Disaggregation of Revenue [Line Items]
Net services revenue	$ 1,806.4	$ 1,474.6	$ 1,270.8
Net operating fees
Disaggregation of Revenue [Line Items]
Net services revenue	1,309.7	1,211.8	1,093.8
Incentive fees
Disaggregation of Revenue [Line Items]
Net services revenue	106.8	143.8	70.6
Modular and other
Disaggregation of Revenue [Line Items]
Net services revenue	$ 389.9	$ 119	$ 106.4

Revenue Recognition - Schedul_2

Revenue Recognition - Schedule of Contract Balances (Details) - USD ($) $ in Millions	Dec. 31, 2022	Jun. 30, 2022	Dec. 31, 2021
Contract assets, net
Current	$ 83.9		$ 0
Non-current	32		0
Total contract assets, net	115.9	$ 89.6	0
Contract liabilities
Current	9.7		10.3
Non-current	18.7		18.7
Total contract liabilities	28.4		29
Current portion of customer liabilities	7.6		7.8
Non-current portion of customer liabilities	5		3.3
Investor
Contract liabilities
Current portion of customer liabilities	2.1		2.5
Non-current portion of customer liabilities	$ 13.7		$ 15.4

Revenue Recognition - Changes t

Revenue Recognition - Changes to Contract Assets (Details) $ in Millions	6 Months Ended
	Dec. 31, 2022 USD ($)
Contract Assets
Balance as of June 30, 2022	$ 89.6
Revenue recognized	172.9
Amounts billed	(151)
Other	4.4
Balance as of December 31, 2022	$ 115.9

Revenue Recognition - Narrative

Revenue Recognition - Narrative (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2022	Dec. 31, 2021
Disaggregation of Revenue [Line Items]
Revenue recognized	$ 94.8	$ 98
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	$ 85.8	$ 88.1

Revenue Recognition - Transacti

Revenue Recognition - Transaction Price Allocated to the Remaining Performance Obligation (Details) $ in Millions	Dec. 31, 2022 USD ($)
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	$ 434.4
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	$ 27
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	$ 115.4
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	$ 27
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	$ 82.5
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]: 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	$ 39.3
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]: 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	1 year
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	$ 38.2
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]: 2027-01-01
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]: 2027-01-01 | 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	$ 34.1
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2027-01-01 | 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]: 2028-01-01
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]: 2028-01-01 | 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	$ 124.9
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2028-01-01 | 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

Accounts Receivable and Allow_3

Accounts Receivable and Allowance for Credit Losses - Narrative (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2022	Dec. 31, 2021	Dec. 31, 2020
Accounts, Notes, Loans and Financing Receivable [Line Items]
Increase in allowance	$ 11.1	$ 0.7
Initial increase, allowance for credit losses	15.2	$ 2.5	$ 3.8
Contract assets	2.2
Physician Customer
Accounts, Notes, Loans and Financing Receivable [Line Items]
Increase in allowance	9.6
Initial increase, allowance for credit losses	10.1
Accounts receivable, gross	$ 32.6

Accounts Receivable and Allow_4

Accounts Receivable and Allowance for Credit Losses - Schedule of Allowance for Credit Losses Related to Accounts Receivable (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2022	Dec. 31, 2021
Accounts Receivable, Allowance for Credit Loss [Roll Forward]
Beginning balance	$ 2.5	$ 3.8
Provision (recoveries)	11.1	0.7
Write-offs	(0.2)	(2)
Ending balance	15.2	2.5
ASC 326 | Cloudmed
Accounts Receivable, Allowance for Credit Loss [Roll Forward]
Beginning balance	$ 1.8	0
Ending balance		$ 1.8

Leases - Narrative (Details)

Leases - Narrative (Details) $ in Millions	3 Months Ended
	Dec. 31, 2022 USD ($)
Lessee, Lease, Description [Line Items]
Right of use asset impairments	$ 17
Maximum
Lessee, Lease, Description [Line Items]
Operating lease, term (up to)	11 years
Operating 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, 2022	Dec. 31, 2021
Leases [Abstract]
Operating lease cost	$ 22.1	$ 15.8
Sublease income	(1.6)	(2.3)
Total lease cost	$ 20.5	$ 13.5

Leases - Schedule of Supplement

Leases - Schedule of Supplemental Information Related to Operating Leases (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2022	Dec. 31, 2021
Leases [Abstract]
Weighted average remaining lease term	7 years	7 years
Weighted average incremental borrowing rate	6.52%	8.10%
Cash paid for amounts included in the measurement of lease liabilities:
Operating cash flows for operating leases	$ 27	$ 22.8
ROU assets obtained or acquired in exchange for operating lease obligations	$ 67.7	$ 20.3

Leases - Schedule of Operating

Leases - Schedule of Operating Lease Maturity (Details) $ in Millions	Dec. 31, 2022 USD ($)
Operating Leases
2023	$ 24.6
2024	23.9
2025	22.6
2026	16.8
2027	10.7
Thereafter	40.7
Total	139.3
Less:
Imputed interest	26.9
Present value of lease liabilities	$ 112.4

Customer Liabilities - Schedule

Customer Liabilities - Schedule of Customer Liabilities (Details) - USD ($) $ in Millions	Dec. 31, 2022	Dec. 31, 2021
Other Liabilities Disclosure [Abstract]
Accrued service costs, current	$ 21.9	$ 32.3
Collections payable to clients, current	29.1	3
Customer deposits, current	1.5	0
Refund liabilities, current	2.7	3.8
Deferred revenue (contract liabilities), current	9.7	10.3
Current portion of customer liabilities	64.9	49.4
Deferred revenue (contract liabilities), non-current	18.7	18.7
Non-current portion of customer liabilities	18.7	18.7
Total customer liabilities	$ 83.6	$ 68.1

Debt - Carrying Amounts of Debt

Debt - Carrying Amounts of Debt (Details) - USD ($) $ in Millions	Dec. 31, 2022	Dec. 31, 2021
Debt Instrument [Line Items]
Long-term debt	$ 1,810.1
Unamortized discount and issuance costs	(23.6)	$ (3.2)
Total debt	1,786.5	772.4
Less: Current maturities	(53.9)	(17.5)
Total long-term debt	1,732.6	754.9
Senior Revolver | Line of Credit
Debt Instrument [Line Items]
Long-term debt	100	80
Borrowing availability	499.1
Term A Loans | Line of Credit
Debt Instrument [Line Items]
Long-term debt	1,211.4	695.6
Term B Loan | Line of Credit
Debt Instrument [Line Items]
Long-term debt	498.7	$ 0
Letter of Credit | Line of Credit
Debt Instrument [Line Items]
Long-term debt	$ 0.9

Debt - Narrative (Details)

Debt - Narrative (Details)	Jun. 21, 2022 USD ($) offer	Dec. 31, 2022	Jul. 01, 2021 USD ($)
Debt Instrument [Line Items]
Debt covenant, secured obligation pledged, capital stock of certain domestic subsidiaries, percent	100%
Line of Credit
Debt Instrument [Line Items]
Mandatory prepayments, percentage of non-ordinary course asset sales or other dispositions	100%
Mandatory prepayments, percentage of net cash proceeds of debt incurrence	100%
Line of Credit | Second A&R Credit Agreement
Debt Instrument [Line Items]
Debt covenant, number of offers to extend maturity date, if circumstances met (or more) | offer	1
Interest rate		6.57%
Mandatory prepayments, percentage of annual excess cash flow	50%
Line of Credit | Second A&R Credit Agreement | Minimum
Debt Instrument [Line Items]
Commitment fee	0.20%
Line of Credit | Second A&R Credit Agreement | Maximum
Debt Instrument [Line Items]
Commitment fee	0.40%
Line of Credit | Second A&R Credit Agreement | Federal Funds Rate
Debt Instrument [Line Items]
Basis spread on variable rate basis	0.50%
Line of Credit | Second A&R Credit Agreement | SOFR | Interest Rate Option - Basis Spread One
Debt Instrument [Line Items]
Basis spread on variable rate basis	1%
Line of Credit | Second A&R Credit Agreement | SOFR | Interest Rate Option - Basis Spread One | Minimum
Debt Instrument [Line Items]
Basis spread on variable rate basis	0.25%
Line of Credit | Second A&R Credit Agreement | SOFR | Interest Rate Option - Basis Spread One | Maximum
Debt Instrument [Line Items]
Basis spread on variable rate basis	1.50%
Term A Loans | Line of Credit
Debt Instrument [Line Items]
Credit agreement, maximum borrowing capacity			$ 325,000,000
Term A Loans | Line of Credit | Amended Credit Agreement
Debt Instrument [Line Items]
Principal of debt issued			700,000,000
Senior Revolver | Line of Credit
Debt Instrument [Line Items]
Principal of debt issued			100,000,000
Senior Revolver | Line of Credit | Amended Credit Agreement
Debt Instrument [Line Items]
Principal of debt issued			$ 450,000,000
Senior Revolver | Line of Credit | Second A&R Credit Agreement
Debt Instrument [Line Items]
Credit agreement, maximum borrowing capacity	$ 600,000,000
Debt issuance costs incurred	7,200,000
Debt issuance costs, capitalized	6,400,000
Existing Senior Secured Term Loan A | Line of Credit | Second A&R Credit Agreement
Debt Instrument [Line Items]
Credit agreement, maximum borrowing capacity	691,300,000
Incremental Senior Secured Term Loan A | Line of Credit | Second A&R Credit Agreement
Debt Instrument [Line Items]
Credit agreement, maximum borrowing capacity	$ 540,000,000
Debt maturity	5 years
Term B Loan | Line of Credit | Second A&R Credit Agreement
Debt Instrument [Line Items]
Credit agreement, maximum borrowing capacity	$ 500,000,000
Debt maturity	7 years
Interest rate		7.32%
Term B Loan | Line of Credit | Second A&R Credit Agreement | SOFR | Interest Rate Option - Basis Spread One
Debt Instrument [Line Items]
Variable rate basis, minimum (not less than)	0.50%
Term B Loan | Line of Credit | Second A&R Credit Agreement | SOFR | Interest Rate Option - Basis Spread Two
Debt Instrument [Line Items]
Variable rate basis, minimum (not less than)	0.50%
Term B Loan | Line of Credit | Second A&R Credit Agreement | SOFR | Interest Rate Option - Basis Spread Two | Minimum
Debt Instrument [Line Items]
Basis spread on variable rate basis	1.25%
Term B Loan | Line of Credit | Second A&R Credit Agreement | SOFR | Interest Rate Option - Basis Spread Two | Maximum
Debt Instrument [Line Items]
Basis spread on variable rate basis	2.50%
Term A Loans | Line of Credit | Second A&R Credit Agreement | SOFR | Interest Rate Option - Basis Spread One
Debt Instrument [Line Items]
Variable rate basis, minimum (not less than)	0%
Term A Loans | Line of Credit | Second A&R Credit Agreement | SOFR | Interest Rate Option - Basis Spread Two
Debt Instrument [Line Items]
Variable rate basis, minimum (not less than)	0%

Debt - Schedule of Maturities o

Debt - Schedule of Maturities of Long-term Debt (Details) $ in Millions	Dec. 31, 2022 USD ($)
Debt Disclosure [Abstract]
2023	$ 53.9
2024	67
2025	67
2026	718.3
2027	430.2
Thereafter	473.7
Total	$ 1,810.1

Derivative Financial Instrume_3

Derivative Financial Instruments - Narrative (Details) - USD ($) $ in Millions		12 Months Ended
	Jul. 05, 2022	Dec. 31, 2022	Dec. 31, 2021
Derivative [Line Items]
Accumulated gain, net of tax, recognized in other comprehensive loss		$ 9.9	$ 0.7
Third Party
Derivative [Line Items]
Potential business combination, expected purchase price	$ 150
Designated as Hedging Instrument | Cash Flow Hedging | 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		(1.4)	1.4
Notional amount		126.4	84.3
Designated as Hedging Instrument | Cash Flow Hedging | Interest rate swaps
Derivative [Line Items]
Gain (loss) reported in accumulated other comprehensive income		13.7
Gain (loss) to be reclassified within next 12 months		8.7
Derivatives, net gain (loss) reclassified into cost of services		(0.2)	(1.5)
Notional amount		$ 500	$ 100

Derivative Financial Instrume_4

Derivative Financial Instruments- Schedule Of Derivative Instruments as Hedged on Consolidated Balance Sheets (Details) - USD ($) $ in Millions	Dec. 31, 2022	Dec. 31, 2021
Derivative [Line Items]
Derivative assets	$ 8.8	$ 1.7
Foreign currency forward contracts | Cash Flow Hedging | Designated as Hedging Instrument
Derivative [Line Items]
Derivative assets	0.1	1.7
Derivative liability	0.5	0
Derivative, fair value, net	0.6	1.7
Interest rate swaps | Cash Flow Hedging | Designated as Hedging Instrument
Derivative [Line Items]
Derivative assets	8.7	0
Derivative asset, noncurrent	5	0
Derivative liability	0	0.7
Derivative, fair value, net	$ 13.7	$ 0.7

Stockholders' Equity - Narrativ

Stockholders' Equity - Narrative (Details)			12 Months Ended
	Jan. 19, 2021	Feb. 16, 2016 USD ($) $ / shares shares	Dec. 31, 2022 USD ($) vote $ / shares shares	Dec. 31, 2021 USD ($) $ / shares shares	Jan. 09, 2022 USD ($)	Oct. 22, 2021 USD ($)	Dec. 31, 2020 shares	Dec. 31, 2019 shares	Jan. 23, 2018 $ / shares shares	Nov. 13, 2013 USD ($)
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 | $					$ 500,000,000	$ 200,000,000				$ 50,000,000
Stock repurchased during period, shares (in shares)			2,080,518	2,629,257
Treasury stock, shares retired (in shares)			0	0
Treasury stock, shares (in shares)			23,352,240	20,094,686
Common Stock Repurchase Programs
Class of Stock [Line Items]
Treasury stock, shares (in shares)			10,031,168	7,950,650
Restricted Stock Awards and Restricted Stock Units
Class of Stock [Line Items]
Shares paid for tax withholding for share-based compensation (in shares)			1,174,754	796,908
Redeemable Convertible Preferred Stock
Class of Stock [Line Items]
Temporary equity, shares outstanding (in shares)			0	0			288,497	266,529
TCP-ASC ACHI Series LLLP and Intermountain | Common Stock
Class of Stock [Line Items]
Warrants, shares outstanding (in shares)			42,000,000	42,000,000
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%		8%
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 | Investor
Class of Stock [Line Items]
Preferred stock, dividend rate		8%
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
	Jun. 21, 2022 shares	May 20, 2021 shares	Dec. 31, 2016 shares	Dec. 31, 2022 USD ($) plan $ / shares shares	Dec. 31, 2021 USD ($) $ / shares	Dec. 31, 2020 USD ($) $ / shares
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Number of stock incentive plans | plan				3
Maximum number of shares issuable under plan (in shares) (up to)				55,974,756
Income tax benefit, vesting and exercises of equity awards | $				$ 9.8	$ 12.7	$ 37.3
Weighted-average grant date fair value of options granted (in dollars per share) | $ / shares				$ 9.55	$ 9.34	$ 4.41
Total intrinsic value of options exercised | $				$ 26.5	$ 38.2	$ 30.5
Total fair value of options vested | $				$ 0.1	$ 1.4	$ 2.2
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 Units (RSUs) | Cloudmed
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Replacement awards issued to Cloudmed equity award holders, shares (in shares)	1,536,220
Restricted Stock Units (RSUs) And Performance Shares | Cloudmed
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Replacement awards issued to Cloudmed equity award holders, shares (in shares)	3,173,184
Performance-Based Restricted Stock Units (PBRSUs)
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Maximum number of shares that could vest (in shares)				13,753,594
Performance-Based Restricted Stock Units (PBRSUs) | Minimum
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Number of shares vesting if price targets met, potential percentage of the number originally granted				0%
Performance-Based Restricted Stock Units (PBRSUs) | Maximum
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Number of shares vesting if price targets met, potential percentage of the number originally granted				200%
Former Class P Units
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Number of units converted in Transaction Agreement (in shares)	97,875
Management Units
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Nonvested award, cost not yet recognized, period for recognition				4 years
Number of units converted in Transaction Agreement (in shares)	514,986
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)		9,600,000	17,000,000
Stock Incentive Plan 2010
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Available for future grant (in shares)				7,348,028
Inducement Plan
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Available for future grant (in shares)	6,225,000			259,372

Share-Based Compensation - Assu

Share-Based Compensation - Assumptions (Details)	12 Months Ended
	Dec. 31, 2022	Dec. 31, 2021	Dec. 31, 2020
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Expected dividend yield	0%	0%	0%
Risk-free interest rate, minimum	1.40%	0.40%	0.30%
Risk-free interest rate, maximum	3.30%	1%	1.70%
Expected volatility, minimum	43%
Expected volatility, maximum	50%
Expected volatility		43%	43%
Expected term (in years)		5 years 6 months	5 years 6 months
Minimum
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Expected term (in years)	4 years
Maximum
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Expected term (in years)	5 years 6 months

Share-Based Compensation - Comp

Share-Based Compensation - Compensation Expense Allocation (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2022	Dec. 31, 2021	Dec. 31, 2020
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Total share-based compensation expense	$ 67.1	$ 74.3	$ 24.1
Share-based compensation expense capitalized to deferred contract costs	0.3	0.6	0.1
CoyCo 2
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Share-based compensation expense capitalized to deferred contract costs	5.1
Cost of services
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Total share-based compensation expense	28.8	44.2	9.9
Selling, general and administrative
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Total share-based compensation expense	38.2	30.1	14.1
Other
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Total share-based compensation expense	$ 0.1	$ 0	$ 0.1

Share-Based Compensation - Stoc

Share-Based Compensation - Stock Option Activity (Details) - USD ($) $ / shares in Units, $ in Millions	12 Months Ended
	Dec. 31, 2022	Dec. 31, 2021	Dec. 31, 2020	Dec. 31, 2019
Shares
Outstanding at beginning of period (in shares)	4,386,205	6,220,971	10,680,340
Granted (in shares)	24,344	6,424	80,425
Exercised (in shares)	(1,285,228)	(1,819,039)	(3,156,154)
Canceled/forfeited (in shares)	(13,408)	(15,151)	(169,420)
Expired (in shares)	(7,500)	(7,000)	(1,214,220)
Outstanding at end of period (in shares)	3,104,413	4,386,205	6,220,971	10,680,340
Outstanding, vested and exercisable at end of period (in shares)	3,080,069	4,365,759	5,230,690
Weighted- Average Exercise Price
Outstanding at beginning of period (in dollars per share)	$ 3.37	$ 3.68	$ 5.59
Granted (in dollars per share)	22.19	23.33	11.18
Exercised (in dollars per share)	3.67	4.39	6.13
Canceled/forfeited (in dollars per share)	4.59	5.98	3.32
Expired (in dollars per share)	8.71	27.08	14.62
Outstanding at end of period (in dollars per share)	3.38	3.37	3.68	$ 5.59
Outstanding, vested and exercisable at end of period (in dollars per share)	$ 3.23	$ 3.33	$ 3.73
Weighted- Average Remaining Contractual Term (in years)
Outstanding at end of period	4 years	4 years 10 months 24 days	5 years 8 months 12 days	5 years 6 months
Outstanding, vested and exercisable at end of period	4 years	4 years 10 months 24 days	5 years 6 months
Aggregate Intrinsic Value (in millions)
Outstanding at end of period	$ 23.9	$ 97	$ 126.5	$ 81.1
Outstanding, vested and exercisable at end of period	$ 23.9	$ 96.7	$ 106.2

Share-Based Compensation - Rest

Share-Based Compensation - Restricted Stock Unit and Performance-Based Restricted Stock Unit Activity (Details) - USD ($) $ / shares in Units, $ in Millions	12 Months Ended
	Dec. 31, 2022	Dec. 31, 2021	Dec. 31, 2020
Restricted Stock Units (RSUs)
RSUs
Outstanding and unvested at beginning of period (in shares)	2,218,651	2,108,447	1,373,356
Granted (in shares)	2,306,897	2,251,167	1,588,120
Performance factor adjustment (in shares)	0	0	0
Vested (in shares)	(1,029,491)	(1,739,847)	(504,708)
Forfeited (in shares)	(264,055)	(401,116)	(348,321)
Outstanding and unvested at end of period (in shares)	3,232,002	2,218,651	2,108,447
Weighted- Average Grant Date Fair Value
Outstanding and unvested at beginning of period (in dollars per share)	$ 16.28	$ 9.87	$ 8.03
Granted (in dollars per share)	20.56	24.35	10.29
Performance factor adjustment (in dollars per share)	0	0	0
Vested (in dollars per share)	16.61	19.14	6.74
Forfeited (in dollars per share)	18.22	15.48	9.09
Outstanding and unvested at end of period (in dollars per share)	$ 19.07	$ 16.28	$ 9.87
Shares surrendered for taxes (in shares)	369,900	571,182	141,331
Cost of shares surrendered for taxes	$ 7.4	$ 13.5	$ 1.4
Performance-Based Restricted Stock Units (PBRSUs)
RSUs
Outstanding and unvested at beginning of period (in shares)	3,203,013	2,917,071	4,119,436
Granted (in shares)	5,230,483	1,071,431	1,637,581
Performance factor adjustment (in shares)	876,109	101,937	3,879,186
Vested (in shares)	(1,925,203)	(586,071)	(6,344,151)
Forfeited (in shares)	(507,605)	(301,355)	(374,981)
Outstanding and unvested at end of period (in shares)	6,876,797	3,203,013	2,917,071
Weighted- Average Grant Date Fair Value
Outstanding and unvested at beginning of period (in dollars per share)	$ 16.45	$ 11.35	$ 6.37
Granted (in dollars per share)	19.83	25.36	13.25
Performance factor adjustment (in dollars per share)	10.46	9.81	14.72
Vested (in dollars per share)	11.05	7.67	13.11
Forfeited (in dollars per share)	20.38	13.55	6.66
Outstanding and unvested at end of period (in dollars per share)	$ 19.48	$ 16.45	$ 11.35
Shares surrendered for taxes (in shares)	804,854	225,726	2,740,924
Cost of shares surrendered for taxes	$ 20.2	$ 5.6	$ 64.2

Other Expenses - Other Costs (D

Other Expenses - Other Costs (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2022	Dec. 31, 2021	Dec. 31, 2020
Other Income and Expenses [Abstract]
Severance and related employee benefits	$ 1.2	$ 2.2	$ 6.4
Business acquisition costs	74.5	4	16.7
Integration costs	40.2	2.6	5.4
Strategic initiatives	23.2	9.1	7.2
Global business services center expansion project in the Philippines	26.7	1.8	0
Customer employee transition and restructuring expenses	(0.4)	4.9	(0.2)
Facility-exit charges	7.9	3.4	17.5
Other	10.2	18.1	14.3
Other expenses	$ 183.5	46.1	67.3
Number of years since new country entry	15 years
COVID-19 related costs, included in Other	$ 2.5	$ 11.3	$ 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, 2022	Dec. 31, 2021	Dec. 31, 2020
Income Tax Disclosure [Abstract]
Domestic	$ (81)	$ 110.1	$ 99.4
Foreign	20	16.7	19
Income (loss) before income tax provision (benefit)	$ (61)	$ 126.8	$ 118.4

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, 2022	Dec. 31, 2021	Dec. 31, 2020
Current
U.S. Federal	$ 0.9	$ (0.1)	$ 0.2
State & Local	3.9	3.4	0
Foreign	3.2	3	2.4
Current Income Tax Expense (Benefit)	8	6.3	2.6
Deferred
U.S. Federal	(11.5)	21.7	(0.3)
State & Local	(5)	0	1
Foreign	5.1	1.6	(2)
Deferred Income Tax Expense (Benefit)	(11.4)	23.3	(1.3)
Total
U.S. Federal	(10.6)	21.6	(0.1)
State & Local	(1.1)	3.4	1
Foreign	8.3	4.6	0.4
Total Current and Deferred Income Tax Expense (Benefit)	$ (3.4)	$ 29.6	$ 1.3

Income Taxes - Schedule of Effe

Income Taxes - Schedule of Effective Income Tax Rate Reconciliation (Details)	12 Months Ended
	Dec. 31, 2022	Dec. 31, 2021	Dec. 31, 2020
Income Tax Disclosure [Abstract]
Federal statutory tax rate	21%	21%	21%
Change in income tax rate resulting from:
State and local income taxes, net of federal tax benefits	1%	2%	1%
Additional tax on foreign source income	(12.00%)	3%	3%
Share-based compensation	20%	(8.00%)	(24.00%)
Non-deductible expenses	(23.00%)	5%	13%
Gain on sale	0%	0%	(11.00%)
Other	(1.00%)	0%	(2.00%)
Effective tax rate	6%	23%	1%

Income Taxes - Schedule of Net

Income Taxes - Schedule of Net Deferred Tax (Details) - USD ($) $ in Millions	Dec. 31, 2022	Dec. 31, 2021
Deferred tax assets and liabilities:
Net operating loss carryforwards	$ 50	$ 54.7
Share-based compensation	16.6	12.2
Accrued bonus	13.7	8.5
Advanced billing revenue	6.8	7.2
Alternative minimum tax	6.2	6.4
Interest expense limitation	11.1	0.1
Deferred rent liabilities	29.1	19.3
Deferred FICA liability	0	3
Fixed assets	1	0
Other	13.1	12.3
Total deferred tax assets	147.6	123.7
Intangible assets	(292.6)	(41.7)
Fixed assets	0	(1.5)
Deferred contract costs	(8)	(8.7)
Foreign withholding tax	(10.2)	(4.2)
Deferred rent assets	(20)	(13.6)
Less valuation allowances	(7.1)	(6.4)
Net deferred tax	$ (190.3)
Net deferred tax		$ 47.6

Income Taxes - Narrative (Detai

Income Taxes - Narrative (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2022	Dec. 31, 2021	Dec. 31, 2020
Income Tax Examination [Line Items]
Valuation allowance	$ 7.1	$ 6.4
Current tax provision	8	6.3	$ 2.6
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 and Development
Income Tax Examination [Line Items]
Valuation allowance	$ 3.4
SCI Acquisition | Deferred Tax Assets, Tax Credit Carryforwards, Capital Loss
Income Tax Examination [Line Items]
Valuation allowance	2.2
U.S. Federal
Income Tax Examination [Line Items]
Operating loss carryforwards	181.5
State
Income Tax Examination [Line Items]
Operating loss carryforwards	223.4
Valuation allowance	7.1	6.4
India
Income Tax Examination [Line Items]
Current tax provision	3.2	3	2.4
Benefit from tax holiday	$ 4.9	$ 4.7	$ 4.3

8.00% Series A Convertible Pr_3

8.00% Series A Convertible Preferred Stock - Narrative (Details) - USD ($)				1 Months Ended	12 Months Ended
	Jan. 19, 2021	Jan. 15, 2021	Feb. 16, 2016	Jan. 31, 2021	Dec. 31, 2022	Dec. 31, 2021	Dec. 31, 2020
Temporary Equity [Line Items]
Cash paid, stock conversion					$ 0	$ 105,000,000	$ 0
Dividends					0	592,300,000	22,400,000
Accrued dividends					$ 0	$ 0	5,800,000
Dividends paid in cash				$ 940
TCP-ASC ACHI Series LLLP
Temporary Equity [Line Items]
Warrant exercise price (in dollars per share)			$ 3.50
Cash paid, stock conversion		$ 105,000,000
Dividends	$ 592,300,000
Redeemable Convertible Preferred Stock
Temporary Equity [Line Items]
Number of shares converted (in shares)						294,266
Liquidation preference per share (in dollars per share)					$ 1,000
Accrued dividends							5,800,000
Dividends paid in additional shares of Preferred Stock							5,800,000
Dividends paid or accrued							$ 22,400,000
Redeemable Convertible Preferred Stock | TCP-ASC ACHI Series LLLP
Temporary Equity [Line Items]
Preferred stock, dividend rate	8%				8%
Preferred stock, shares issued (in shares)			200,000
Preferred stock, issued, value			$ 200,000,000
Long-term purchase commitment, period			10 years
Number of shares converted (in shares)		294,266
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
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, 2021	Dec. 31, 2020
Shares Issued and Outstanding
Beginning Balance (in shares)	288,497	266,529
Dividends paid/accrued dividends (in shares)	5,769	21,968
Conversion of Preferred Stock (in shares)	(294,266)
Ending Balance (in shares)	0	288,497
Carrying Value
Beginning Balance	$ 251.5	$ 229.1
Dividends paid/accrued dividends	0	22.4
Conversion of Preferred Stock	(251.5)
Ending Balance	$ 0	$ 251.5

Earnings (Loss) Per Share - Com

Earnings (Loss) Per Share - Computation of Basic and Diluted Earnings Per Share (Details) - USD ($) $ / shares in Units, $ in Millions		12 Months Ended
	Jan. 19, 2021	Dec. 31, 2022	Dec. 31, 2021	Dec. 31, 2020
Basic EPS:
Net income (loss)		$ (57.6)	$ 97.2	$ 117.1
Less dividends on preferred shares		0	(592.3)	(22.4)
Less income allocated to preferred shareholders		0	0	(47.3)
Net income (loss) available/allocated to common shareholders - basic		(57.6)	(495.1)	47.4
Diluted EPS:
Less income allocated to preferred shareholders		0	0	(37.7)
Net income (loss) available/allocated to common shareholders - diluted		$ (57.6)	$ (495.1)	$ 57
Basic weighted-average common shares (in shares)		352,337,767	266,183,565	115,729,645
Add: Effect of dilutive equity awards (in shares)		0	0	12,731,424
Add: Effect of dilutive warrants (in shares)		0	0	46,112,201
Diluted weighted average common shares (in shares)		352,337,767	266,183,565	174,573,270
Net income (loss) per common share (basic) (in dollars per share)		$ (0.16)	$ (1.86)	$ 0.41
Net income (loss) per common share (diluted) (in dollars per share)		$ (0.16)	$ (1.86)	$ 0.33
TCP-ASC ACHI Series LLLP
Basic EPS:
Less dividends on preferred shares	$ (592.3)
TCP-ASC ACHI Series LLLP | Redeemable Convertible Preferred Stock
Diluted EPS:
Preferred stock, dividend rate, percentage	8%	8%

Earnings (Loss) Per Share - Nar

Earnings (Loss) Per Share - Narrative (Details) - shares	12 Months Ended
	Dec. 31, 2022	Dec. 31, 2021	Dec. 31, 2020
Antidilutive Securities Excluded from Computation of Earnings Per Share [Line Items]
Antidilutive securities excluded from computation of earnings per share (in shares)	20,090,009	12,875,730	97,244
Warrant
Antidilutive Securities Excluded from Computation of Earnings Per Share [Line Items]
Antidilutive securities excluded from computation of earnings per share (in shares)	42,000,000	42,000,000

Commitments and Contingencies -

Commitments and Contingencies - Narrative (Details)	Apr. 19, 2021 claim
TCP-ASC Recapitalization Litigation | Pending Litigation
Loss Contingencies [Line Items]
Number of complaints filed	2

Related Party Transactions - Na

Related Party Transactions - Narrative (Details) - $ / shares				12 Months Ended
	May 28, 2021	Jan. 19, 2021	Feb. 16, 2016	Dec. 31, 2022	Dec. 31, 2021
Common Stock
Related Party Transaction [Line Items]
Exercise of warrants pursuant to cashless provisions (in shares)					16,750,000
TCP-ASC ACHI Series LLLP
Related Party Transaction [Line Items]
Warrant exercise price (in dollars per share)			$ 3.50
Redeemable Convertible Preferred Stock | TCP-ASC ACHI Series LLLP
Related Party Transaction [Line Items]
Preferred stock, dividend rate, percentage		8%		8%
Ascension | Redeemable Convertible Preferred Stock | TCP-ASC ACHI Series LLLP
Related Party Transaction [Line Items]
Preferred stock, dividend rate, percentage			8%
Related Party | TCP-ASC ACHI Series LLLP
Related Party Transaction [Line Items]
Warrant exercise price (in dollars per share)	$ 3.50
Related Party | TCP-ASC ACHI Series LLLP | Minimum
Related Party Transaction [Line Items]
Warrant market value price (in dollars per share)	24.54
Related Party | TCP-ASC ACHI Series LLLP | Maximum
Related Party Transaction [Line Items]
Warrant market value price (in dollars per share)	$ 24.64
Related Party | TCP-ASC ACHI Series LLLP | Common Stock
Related Party Transaction [Line Items]
Exercise of warrants pursuant to cashless provisions (in shares)	16,750,000
Number of securities called by warrants (in shares)	19,535,145

Related Party Transactions - Su

Related Party Transactions - Summary Amounts Included in Balance Sheet (Details) - USD ($) $ in Millions	Dec. 31, 2022	Dec. 31, 2021
Related Party Transaction [Line Items]
Collections payable to clients, current	$ 29.1	$ 3
Refund liabilities, current	2.7	3.8
Deferred revenue (contract liabilities), current	9.7	10.3
Current portion of customer liabilities	64.9	49.4
Deferred revenue (contract liabilities), non-current	18.7	18.7
Non-current portion of customer liabilities	18.7	18.7
Total customer liabilities	83.6	68.1
Ascension
Related Party Transaction [Line Items]
Accrued service costs, current	4.3	4.2
Collections payable to clients, current	0.3	0.6
Refund liabilities, current	0.7	0.6
Deferred revenue (contract liabilities), current	2.1	2.5
Current portion of customer liabilities	7.4	7.9
Deferred revenue (contract liabilities), non-current	13.7	15.4
Non-current portion of customer liabilities	13.7	15.4
Total customer liabilities	$ 21.1	$ 23.3

Segments and Customer Concent_3

Segments and Customer Concentrations - Narrative (Details) - segment	12 Months Ended
	Dec. 31, 2022	Dec. 31, 2021
Segment Reporting Information [Line Items]
Number of operating segments	1
Number of reportable segments	1
Accounts Receivable | Customer Concentration Risk | Ascension and its affiliates
Segment Reporting Information [Line Items]
Concentration percentage	10%	17%

Segments and Customer Concent_4

Segments and Customer Concentrations - Concentration Risk by Customer (Details) - Sales Revenue - Customer Concentration Risk	12 Months Ended
	Dec. 31, 2022	Dec. 31, 2021	Dec. 31, 2020
Ascension and its affiliates
Concentration Risk [Line Items]
Concentration percentage	49%	61%	64%
Intermountain Healthcare
Concentration Risk [Line Items]
Concentration percentage	12%	14%	14%

Retirement Plan - Narrative (De

Retirement Plan - Narrative (Details) - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2022	Dec. 31, 2021	Dec. 31, 2020
Retirement Benefits [Abstract]
Company contributions to the plan	$ 13.3	$ 9.1	$ 3.6

Supplemental Financial Inform_3

Supplemental Financial Information - Schedule of Prepaid Expenses and Other Current Assets (Details) - USD ($) $ in Millions	Dec. 31, 2022	Dec. 31, 2021
Deferred Costs, Capitalized, Prepaid, and Other Assets Disclosure [Abstract]
Prepaid expenses	$ 35.1	$ 27.8
Acquisition and disposition contingent assets	20	29.1
Notes receivable	12	1
Derivative assets	8.8	1.7
Healthcare rebates receivable	5.9	4.5
Deferred contract costs	5.1	3.7
Other current assets	23.4	9.4
Total prepaid expenses and other current assets	$ 110.3	$ 77.2

Supplemental Financial Inform_4

Supplemental Financial Information - Schedule of Accrued Compensation and Benefits (Details) - USD ($) $ in Millions	Dec. 31, 2022	Dec. 31, 2021
Deferred Costs, Capitalized, Prepaid, and Other Assets Disclosure [Abstract]
Accrued expenses	$ 36.4	$ 33.8
Notes payable	15.5	8.3
Acquisition deferred payments	12.5	12.5
Other current liabilities	6.2	4.5
Total accrued expenses and other current liabilities	$ 70.6	$ 59.1