Good day. My name is Ellie, and I will be your conference operator for today. At this time, I would like to welcome everyone to the R1 RCM Incorporated Conference Call. All lines have been placed on mute to prevent any background noise. After the speakers' remarks, there will be a question-and-answer session. [Operator Instructions] Thank you.

Evan Smith, you may now begin the conference..

Thank you, operator, and good morning. Certain statements made during this call may be considered forward-looking statements pursuant to the safe harbor provisions of the Private Securities Litigation Reform Act of 1995.

In particular, any statements about our future growth plans and performance, including statements about our strategic and cost savings initiatives, our liquidity position, our growth opportunities and our future financial performance are forward-looking statements.

These statements are often identified by the use of words such as anticipate, believe, estimate, intend, design, may, plan, project, would and similar expressions or variations. Investors are cautioned not to place undue reliance on such forward-looking statements. All forward-looking statements made on today's call involve risks and uncertainties.

While we may elect to update these forward-looking statements at some point in the future, we have no current intention of doing so except to the extent required by applicable law.

Our results and our outcomes may differ materially from those included in these forward-looking statements and as a result of various factors, including, but not limited to, economic downturns and market conditions beyond our control, including high inflations, the quality of global financial markets, or the ability to timely and successfully achieve the anticipated benefits of potential synergies of the acquisitions of Cloudmed and Acclara, our ability to retain existing customers or acquire new customers, the development of markets for our revenue cycle management offering, variability in lead time of prospective customers, competition within the market and factors discussed under the heading Risk Factors in our most recent annual report on Form 10-K.

Certain results that will be referenced on this call may be rounded to the nearest whole number. We will also be referencing non-GAAP metrics on this call. For reconciliation of non-GAAP metrics to the most closely comparable GAAP metrics, please refer to our press release.

Lee?.

one, ensuring our go-to-market strategy aligns with our customers' needs in order to meet them wherever they are in the revenue cycle journey; two, continuing to deliver excellent results to our customers who have recently onboarded or who have long-standing relationships with R1; three, executing against our technology roadmap to drive measurable results; and four, focusing on operational excellence to drive improved financial performance, which in turn will deliver improved shareholder value.

Now, let me turn it over to Jennifer to discuss financials..

number one, delivering value for our existing customers; two, expanding our market position with new customers, including Providence and other new modular wins; three, operating discipline and execution; and four, automation through technology.

We are optimistic that our focus in these areas will allow us to deliver sustainable revenue growth, operating profit and free cash flow in 2024 and beyond. Operator, I will now turn it back over to you..

[Operator Instructions] Our first question comes from Craig Hettenbach from Morgan Stanley. Your line is now open..

Yes, thank you. Just starting with Cloudmed, any additional color on the next phase of synergies for $20 million this year? What's key to driving that? And then also, there's been some concerns about slowing or moderating growth in Cloudmed, but mid-teens growth looks good for 2024.

So, just wanted to get some more color, Lee, in terms of visibility you mentioned and key drivers that could help sustain the mid-teens growth in Cloudmed..

Thanks, Craig. Let me start at the highest level with Cloudmed.

So, as you and others know, this is a business that helps providers identify sources of revenue leakage through broad data technology and AI-driven platform that cuts across many use cases and has 500-plus customers, 95 of the top 100 systems of NPR, and has grown really strongly the last couple of years. I'll answer your question in a few ways.

One, the business had very strong bookings last year, which is our proxy for ARR, which gives us confidence in what Jennifer highlighted in the growth rate this year.

The growth comes from all our solutions, with particular focus on some of our denials and AR solutions which deploy a technology platform to help providers in that area, in a place where we've seen some increases post COVID, and the market has been -- the customers have been very receptive to our strategy which is essentially to land and expand cross-sell solutions into the base.

So, we feel very confident coming into the year on the growth rate. We expect to have another strong year of bookings, and feel really good about how we're progressing that business.

Over the long run, we haven't given guidance on '25, '26, but we expect continued strong growth, but obviously over the long run, as the business gets bigger, you could see growth rates changing a bit. On the synergy side, just to back up, we feel -- I'm very proud of the teams on what they've accomplished on behalf of the business, our customers.

We've achieved our synergy targets in the first two years largely through solid execution. The experience the business has in integrating, and by the way, also gives us a lot of confidence on execution related to Acclara, just a playbook that has worked across multiple dimensions. So, this year, the $20 million we also feel good about this.

The biggest opportunity for us is continued automation, continued deployment of rules and analytics to drive down costs and identify synergy opportunities and moving resources really as we incrementally hire resources, doing more of that hiring in our global facilities.

That's the main driver of the $20 million, as well as a few other areas we can go into detail later. But overall, feel very good about both the quality of the business, the receptiveness of the marketing customers for those solutions and our synergy targets.

Anything to add, Jennifer?.

No, the only thing I would add is in 2023 most of the synergies were driven by G&A functions, integration of all the back-office systems and more of the corporate teams, facility rationalization, et cetera.

So, as Lee indicated, in 2024 most of the synergy realization will come from the operational integration, primarily related to the global transitions..

That's helpful. And then, just a quick follow up. Lee, I want to touch on just how the strategy has evolved under your leadership, kind of seeing a more balanced approach between growth, focus on margins and cash flow.

And if you can just touch on how that shapes kind of your priorities for this year and beyond?.

Yeah, so Craig, great question.

So, let me just step back and say, look, we, the team feel very good about the fundamental growth prospects for the entire business, okay? That said, we have talked a lot in my first year as CEO about the end-to-end business, and today we have a much more diversified business, right? A lot less customer concentration, the Cloudmed business, plus the legacy modular business is a much more substantial part of our business.

So, when I say flexible, you've heard me use that word a couple of times, that means meeting providers wherever they are. You heard the example I gave. There are situations where a prospective customer may say, look, the initial thought is an end-to-end engagement.

And we may say, just like the example I gave, that what is better for that customer given their financial situation, given the dynamics, maybe it's the fragmented nature of their technologies and processes that we should do more of a managed services, use our coding resources, use our AR follow-up resources, our technology, our global scale, and you all, the customer manage that, and then accelerate the adoption of Cloudmed, right, which is a very powerful solution that delivers significant revenue yield or what a customer would know as revenue integrity, identifying sources of revenue they would not otherwise see due to leakage for many reasons.

So, that's the main change in strategy. The other thing I would say is, look, the Cloudmed business has a lot of experience, a lot of capabilities around data platform, analytics, deployment of AI. So, you'll hear me and the team talk about a continuation of the strategy of deploying automation, AI and technology.

Just to give you a little bit of color there, we have a significant right to win in the space of AI and large language models because we are embedded in the customer workflow. So, just think of any end-to-end could be front, middle, back, where you have access to EMRs, the host systems, billing systems, all the data structured and unstructured.

The example I gave is in the denial space, because we see the denials, we know what successful claims looks like, we can deploy AI models to respond to those denials, as an example. And I can give you 10 other examples.

But you'll hear me and Jennifer talk more and more about the adoption of AI, which in turn drives greater revenue yield, lower cost, and just generally increased customer satisfaction and confidence in our growth rates and margin expansion..

Thank you..

Next question comes from Jailendra Singh from Truist Securities. Your line is now open..

Good morning, and thanks for taking my questions. My first question is on customer health. You guys had another $10.5 million of allowance for losses in 4Q. You called out two customers representing a big portion of that.

Can you share how much of your total NPR or revenues these customers represent? And how are you thinking about contribution from these two customers in '24? Are you assuming any reversal of this allowance or even increase? And Lee, beyond those two contracts, if you can comment on generally your customer health in particular?.

Okay. Jailendra, let me start with the last part of your question, then I'll hand over to Jennifer. We made a lot of progress in 2023. So, just to give you the high level on metrics, post COVID, clearly there's been more payer pressure, changes in timelines on payments. We've actually seen increases in certain areas of denials.

But broadly, we have done what we set out to do in '23, which is stabilize core metrics, looked across our scorecards and you've kind of heard what Jennifer said about our incentives remaining flat or moderate growth. So overall, we made a lot of progress. Now, that said, take one metric, Jailendra, HDR, which is a challenge across the industry.

You can look at a lot of data points post COVID on days payable, et cetera. While we've seen those stabilize, they're still elevated post COVID, right? So, depending on an individual customer, we've seen some variance across customers. So, what I would say, Jailendra, is we are not done on performing for our customers.

We have more work to do to continue to improve with some of our newly onboarded customers in '21 and '22, where we need to continue to accelerate automation, adoption of technology, integrating the customers' technologies and processes to drive progress in some areas where there's hotspots at some of our newly onboarded customers.

Large customers, Jailendra, we feel very good about the Phase 1 of Sutter. We're performing well for the largest, most mature customers. So, lots and lots of good things around metrics. I would also say on the customer engagement side, we are doing a couple of things there.

One is deploying our Cloudmed solutions as much as possible, which is a high class rated set of solutions. And we're also just changing our approach on how we engage with customers.

I can go in more detail there, Jailendra, but just really thinking about how can we in our end-to-end business, be even more customer centric as we continue to scale the business, adopt new technologies, deploy automation and AI through the enterprise. So, that's at the high level.

What I would say is a lot of progress in '23, still more work to do in '24.

Jennifer?.

Sure. On the allowance specifically and the size of the customer, I would say one is small, another is mid-size. It is one end-to-end customer and one modular customer. And as far as continuing to do business with them and what the outlook or the guidance assumes, we do expect that we'll continue to still do business with them in 2024.

However, both of the businesses are doing a bit of restructuring in their business, and so that's factored into our guidance..

Okay. And then -- that's helpful. And then, my follow up. I completely understand you guys might not be willing to comment on the New Mountain filing, but Lee and Jennifer, you had experience of successfully running a private company, now you're running a public company.

Just curious about your general views on executing on R1 strategy and approach and creating long-term shareholder value as an independent public company versus contemplating other options to create near-term shareholder value..

Yeah. What I'd say, Jailendra, you're right, I can't comment on a lot of the specifics. Here's what I'd say. Look, we are very confident as a team of the prospects of the business.

There is a high level of end market demand in both end-to-end managed services and Cloudmed, macro growth across the industry and needs, especially for providers who may be struggling with financial pressure, high labor, inconsistent adoption of technology, payer pressure, et cetera.

So, I and the team feel very confident of running this business in any context, okay? So, what I would respond specifically to the question on the letter that came, our Board received a letter. It's reviewing the request.

We will evaluate that letter, the proposal, and we would, as any public company, work with our advisors to determine the course of action that is most beneficial to our shareholders, customers, and employees..

Great. Thanks a lot..

Our next question comes from Stephanie Davis from Barclays. Your line is now open..

Hey, guys, thanks for taking the questions. I have -- you know what, let me start with an AI question, because, Lee, I feel like you really want to talk about that. And I'll get to some questions on Sutter.

But could you tell us a little bit more about what your cost structure could look like as you kind of build out your AI solutions? And how much of it is going to be more near-term investments on the engineering side or the LLM investment side versus the kind of cost yields you can get as you don't have to have as much hiring to build out?.

Yeah. So, let me start with the strategy, and then Jennifer, if you have any questions on cost structure, add in. Look, the reason I am excited, Stephanie, and the team is very excited, is we see a massive value unlock for our customers and shareholders on deploying large language models into our systems, tools and technology.

The examples I gave are all exciting and they barely scratch the surface, Stephanie. So, denials, automating appeals, running the first pass, reducing the need for additional auditing and follow up that has immediate implications to our own cost structure.

Automating, summarizing charts and deploying that in our coding business has immediate value to customers on accelerating cash collections and value related to our cost structure.

AR follow-up sounds benign, Stephanie, but these are thousands of workers we have that are following up on claims and having the ability to summarize a claim through a large language model on claims we see from that payer in that setting, in that geography, reduces the work time for any individual AR follow-up person in our system, and that leads directly to increased cash collection, revenue, speed to revenue, and obviously our overall cost structure.

A couple other things. We've partnered with Microsoft. We feel very good about that partnership. We have a robust roadmap.

This has become at the top of our roadmap, along with automation, along with deployment of data and analytics from our Cloudmed business, and continued net new product innovation that we haven't spent that much time talking about, Stephanie.

But this area gives us a lot of confidence on more rapid deployment of products, shipping new products to our customers into our operating systems, and it's just something we're very excited about.

Jennifer, any thoughts on cost structure?.

As far as the early investments, Stephanie, you're right, it's going to be in two areas. Investments in data to make sure that we can consolidate the data, and we have clean data to be able to deploy in the models, and then engineering to build those large language models, and make sure that they're operating and we're getting the benefits out of it.

Longer term, as Lee mentioned, some of the specific use cases is where we have the largest number of people in coding and auditing, and then on the back-end in follow-up, where we have thousands of people that are doing AR follow-up in some capacity, whether it could be responding to denials, follow-up with payers.

As we deploy these models and we see opportunities to be able to automate that, we'll be able to grow, and the incremental margin on that will be much higher. We're still in the early days, so we're monitoring it very closely, but we feel very good about the opportunity there..

That's helpful. And then, on the Sutter Health side, there's a lot that makes their Phase 2 deployment a little bit more unique, right? They're an EPIC system. They had a management changeover.

Could you give us a little color on kind of what the timeline could be for that and what some of the biggest holdups are? And if there's any potential they would want to keep the front-end in-house?.

Yeah, Stephanie, let me just talk about -- this is a great topic. Let me start with the first phase is a fulsome phase that looks not too dissimilar to the Providence engagement. So, the entirety of the middle and back, that's the first thing I just want to remind everyone. This is a very comprehensive engagement.

You'll notice, Stephanie, that as we articulated how we're moving forward with Providence, we did not phase it on purpose. We have a lot of learnings on how to contract, how to deploy, integrate with a net new customer. You'll hear us do that going forward.

The second thing I'd say is there's always room to improve, but Phase 1, from an operational metric standpoint, has progressed very well. A couple of advantages, if you will, of that deployment is it was a centralized revenue cycle, strong executive leadership and support.

And we already have, in particular through our Cloudmed business, experience with EPIC. So, regarding Phase 2, what I'd say, and just as simply as possible, is we continue to dialogue with the executives, the most senior executives at Sutter. We have not assumed anything in our '24 numbers, and we'll keep you updated each quarter, Stephanie.

But there's no new news. But overall, I look at this as an opportunity in our customer base, just as there are opportunities with all of our other end-to-end customers..

Awesome. Thank you, folks..

Our next question comes from Charles Rhyee from TD Cowen. Your line is now open..

Yeah. Hey, thanks for taking the questions. Jennifer, maybe, and Lee, just wanted to dive into the guidance then for this year. Obviously, a lot of moving parts here with customers coming in and out and some pause here on the Sutter side.

But assuming nothing changes from here, and how should we think about what underlying sort of fundamental EBITDA growth for this business is? Because I would think, particularly, Lee, with all your comments around the opportunity with GenAI, we should see continued margin expansion.

I would imagine a lot of that discussion happened sort of post when you guys were talking about long-term margin targets. Maybe, can you give us a sense? I think, Jennifer, you said at one point, this is at least a 15%-plus EBITDA growth kind of business.

Is that still sort of in your mind frame, or particularly with GenAI, could we expect to see actually faster growth over time?.

Why don't I start, Charles, and then Jennifer, you go. The way I frame it is the following, okay? So, you're right, Charles, you're hearing me be very optimistic about the long-term prospects of the business across all areas, end-to-end, managed services and Cloudmed.

The way I think about it is, and you've heard us say this before, but just to frame it, it's base business maturity. You heard, Jennifer, what you said about the end-to-end base business, the addition of Cloudmed and other modular services, which is incremental to EBITDA and growth.

And then, you get into the topic we just talked about with Stephanie is the adoption -- continued adoption of technology, which is a significant unlock for value for our customers, and additional margin. Then we have synergies, continued Cloudmed synergies, and that's the other factor. Then last, it's Acclara and Providence.

So, the combination of onboarding both the acute and physician business, the assumptions we made this year, potential for us to do even better there in '24, but certainly confidence in '25. And then synergy realization for Acclara, which is really, as you know from what we said, not a ton in '24, but a high confidence in '25 and '26.

So, those are the pieces and parts. Overall, we feel very good about what we've said in guidance and have a lot of confidence in the business.

But, Jennifer, any specifics?.

Specific to EBITDA growth, if you look at the 2024 guidance, the core margins for R1 are improving, and I think that's indicative of the margin maturity, continued growth on the modular side with higher margins and synergy realization, as Lee indicated.

And then, the drivers on the other side, where we're doing a bit of investment, is on the Providence new business, where there's a significant investment in year, and the Acclara business, which is admittedly operating today at a lower margin than what our core business is. And we expect significant synergy realization over the next couple of years.

As far as AI, we're making a lot of investments in the business right now. A lot of those investments will begin to pay back in 2025.

So, there's not a lot of contribution from AI -- significant contribution from those AI investments that we're making in '24, most of that will come in 2025 and beyond, which is part of the reason that we feel good and very confident in the long-term growth..

And if I could follow up. So, if we think -- not to jump too far ahead, but if we think to next year, right, we're going to get back sort of the tailwind from no onboarding costs related to Providence. We're going to get another half year of net operating fee contribution. Obviously, there's a margin to that. Synergies related to Acclara.

Is it hard not to think that we're going to have a significant uplift in growth as we get through this sort of kind of rebasing year?.

We haven't given longer term guidance on '25, but that's the way we're thinking about the business generally.

There will be a lot of growth coming from maturity of the Providence contract as we annualize some of the investments we're making this year, and then start to see some of the benefits -- incremental benefits for AI and some of the automation in the future..

Great. I appreciate it. Thanks..

Our next question comes from Daniel Grosslight from Citi. Your line is now open..

Hi, thanks for taking the question. I'd like to focus on Providence revenue recognition and investment this year.

Really the cadence, how should we think about that as the year progresses? And then, do you have any visibility at this point on the cadence of the pediatrics attrition?.

Let me start with Providence, just the kind of high-level, hand it over to Jennifer, then I'll also cover pediatrics, and if Jennifer has anything to add. So, just to remind everyone, this was a flagship win, very sophisticated buyer, very strong, experienced executive team, and a commercial contract that closed in January.

For the acute and physician business, $14 billion of NPR, not including the Swedish business. Comprehensive engagement for the entirety of the middle and back. We are very much on track with regard to onboarding. We are applying lessons learned from the last large EPIC onboarding, which was Sutter. The teams are working very well.

We are meeting daily, have a lot of just operational checkpoints on making sure that onboarding goes really well. And all the data we have points to a high level of confidence on meeting our timing goals. Guidance assumes revenue second half.

Jennifer, any additional comments on timing?.

Yeah. As far as the phasing, from a revenue perspective, we do expect that revenue will ramp second half of the year, $45 million to $50 million of net operating fees in the second half. And as far as the investments that we're making, we're starting to make investments right out of the gate.

We're starting to ramp resources so that we can deploy and be ready for the transitions that we expect to happen mid-year. So those investments will start in Q1. As far as Acclara, obviously, that revenue will begin to be recognized at the time of close. That's an existing business. So, the $290 million to $295 million of revenue will begin mid-January.

And we've adjusted for the timing of close in that $290 million to $295 million estimate for the year. And there's not a ton of seasonality there, so you can phase that across the year..

Got it. Can you remind us -- sorry, go ahead..

I was just going to say, as far as pediatrics and the transition, our guidance assumes a mid-year transition. The reality is there may be some things that transition earlier in the year, but go a little longer. So, I don't think it's going to be everything transitioned at the end of Q2.

I think there will be some things that will begin to transition in Q2, but will go into the second half of the year as well..

Okay, got it. Okay.

Can you remind us how many employees you have now in the Philippines and how much more juice there is left to squeeze out a margin by further shifting folks to the Philippines in '24?.

Yeah. So, look, this is an area that we don't get to talk about that much, Daniel, so I'm glad you brought up the question, but this is a very valuable global center for us that helps diversify outside of India. We have just over 2,000 people in the facility. Historically, mostly focused on customer service, front-end patient registration and so on.

We've actually had some really good successes with some of our large customers deploying technology, leveraging that facility. So, this is for sure an area we will continue to expand and will deliver opportunities for a lot of value to our customers that deploy not just front-end, but also customer service.

And we're also diversifying outside of other areas. So, we are realizing the value of that facility as it matures, just like India did 10-plus years ago. As it matures, that facility is able to take on more and diversified parts of customer workflow. So overall, I feel really good about the strategy there..

Got it. Thank you..

Our next question comes from Sean Dodge from RBC Capital Markets. Your line is now open..

Yeah, thanks. So, your earlier comments on EBITDA growth, if we bridge that into cash flow, Jennifer, you mentioned stronger performance in 2023, and then, through '24, you've laid out the EBITDA guidance and gave much more detail on CapEx and other items.

I guess if we bake all of this in, how should we be thinking about free cash flow trajectory both into this year? And then, any updates to how we should expect that to unfold over the next couple of years? And maybe what the big drivers of that should be?.

On the cash flow front, we said last year that we expect cash flow for the core R1 business before Providence and Acclara to be in the mid-30% from a cash flow conversion as a percentage of the EBITDA, and that's still the expectation. We had very strong cash flow the second half of this year. So, we feel very confident in that.

There are some investments, as we indicated, on the Providence new business, that will bring down that cash flow conversion in 2024 for Providence as we invest early on in that revenue contract.

And then Acclara with the integration, we expect that it will be a drag on free cash flow in 2024, as we have transaction costs in the first half of the year, we have higher interest expense associated with the debt, and we're going to be integrating the business and realizing costs associated with synergies as we begin to execute on that.

So, the cash flow in 2024 is in the 20%-plus range for 2024. But as we move into 2025 and beyond, we would expect that we continue to improve on what we would look at as that core free cash flow conversion of the mid-30% to continue to increase that. And we've said that that cash flow conversion target is in the 50%-plus range.

So, we still don't think that there's any reason why we wouldn't be able to get to those cash flow conversion rates..

Okay. Great. And then, for this year's guidance, 2024 guidance, can you share what you've assumed or baked in there in terms of credit allowances? There's a lot of noise there in 2023.

Should 2024 be more normal? And then, what does normal look like now you think going forward?.

It will be improved. Our guidance assumes that will be improved off of 2023, but I do think it will still be a bit elevated from a historical number. What new normal looks like is probably in the range of $10 million a year in that range, and that's what's assumed in the 2024 guidance.

So, some improvement coming off of 2024, but still higher than historical -- or 2023, but higher than historical..

Great. Thank you, Jen..

Question comes from Evercore Partner. Your line is now open..

Hi, it's Elizabeth Anderson. So, thanks for the question, guys. One question I had, can you talk, Lee, maybe, about that customer approach change you referenced in your other question? It'd be helpful to hear a little bit more details about that..

Yes, Elizabeth, it's simple. One is just, from a go-to-market standpoint, being a lot more flexible on how we meet the needs for customers. Two is continuing to leverage the Cloudmed customer position, market position to expand into managed services, expand into end-to-end. Three is flexible contracting.

So, Elizabeth, this is kind of think about Providence, right? Could we have pushed harder on the front-end? Could we have pushed harder on some expansion opportunities? For sure, but it's being flexible on what the customer wanted to do and not phasing anything, and just leaving some of the expansion opportunities for later.

The thing I specifically mentioned is, look, as the business has scaled from an operations standpoint, really thinking about how we scale to the next phase of NPR, you could imagine our business over time being a lot more than $70 billion of NPR, right, with just natural tailwinds at the market level, so how do we continue to scale what has historically been a centralized operation, and at what level can we be more customer specific on the operational side.

On the customer-facing side, we've also scaled. So, this means we have to be more aggressive about hiring talent that is customer-facing, be a lot more customer centric in our approach, be more systemic or systematic on how we engage with customers, the level of executive that engages. And this is about expanding our talent pool, really.

And the other thing I would highlight, Elizabeth, as I didn't mention, is deploying a more data and analytic approach and highlighting to customers this macro dynamic that's happening around payer mix, and how that factor is somewhat in our control with some of the payer escalation processes we have.

But to some extent is a macro dynamic, we can help arm our customers to address and paint a picture for them that R1 is best equipped to help them through these. But there are for sure macro dynamics that are maybe less in our control So, I could go deeper in that, Elizabeth. But that's at the high level, what I'm talking about..

Got it. That's super helpful. And I was wondering if there's any more detail that you can provide in terms of how you feel about the pipeline for incremental new deals as we think about 2024 and potential timing on that. Appreciate the additional color on the 4Q win..

Yeah, just the interest of time, Elizabeth, very good. So, good across all fronts, end-to-end, modular. We've learned a lot of lessons from that last year about not projecting a deal, but a couple of color -- pieces of color, the land of large, large deals, $10-plus billion is less and less with some of those choose end-to-end partners.

I do think the next phase of deal is something in the $2 billion, up to $5 billion range. But we have a healthy pipeline on both the end-to-end side, and I expect another strong year of bookings on the Cloudmed and R1 modular side..

Thank you..

Our next question comes from Vikram Kesava from Baird. Your line is now open..

Great. Thank you for taking the questions. I wanted to ask about the incentive fees. It looks like those stepped down sequentially in the fourth quarter. I was curious if you could talk about the drivers there.

I know you called out some one-time factors on the previous conference call, but just wondering if we can get some color on how that ultimately played out relative to your expectations, and what the guidance assumes for incentive fees in 2024.

And then, on a related topic, just wondering if you could talk about just what you're observing more broadly in terms of payer reimbursement timelines. I think in the past you've suggested that you're starting to see signs of stabilization. Just curious if that's still the case or if you're seeing any signs of it getting particularly better or worse.

And I'll leave it there. Thanks..

Sure. On incentive fees, last quarter, we had some one-time items that increased our incentive fees in the quarter, and so we had reflected that we knew we would have a decrease quarter-over-quarter in incentive fees. Incentive fees landed right in line with our expectations, so there was no surprise there. Those one-time fees were really twofold.

One was related to an acceleration of some incentive fees for a contract that ended in Q4, and it accelerated. So, we had extra, if you will, incentive fees in Q3. And then, one was where we had a reclass based on a contractual change, where it's just a reclass out of incentive fees and into net operating fees.

So, it was just a movement, but no change to either total revenue or EBITDA from that perspective. So that's the change. As we look to 2024, we do expect that payer reimbursement timelines, first of all, they stabilized in 2023.

We saw some very modest improvements, kind of quarter-over-quarter, a little bit of puts and takes across the quarter, but very modest improvement year-over-year. And I would expect the same for 2024. I don't think there's going to be significant improvement in payer timelines.

I would love to be pleasantly surprised there, but that's not what we're assuming. So, we expect that those will remain stable to where they were in 2023.

And then, as a result, I expect, given our run rate in Q4 for our existing customer base is kind of at a run rate, I would expect that incentive fees are relatively stable and consistent with what we saw in 2023..

Okay. Thank you..

Our next question comes from Bank of America. Your line is now open..

Good morning. This is Allen Lutz at BofA. One of your largest customers reported really nice revenue growth in the most recent quarter, and it seems like the utilization environment seems to be improving more broadly.

How should we think about your guidance for low single-digit growth of core customers that's embedded in the guide? How does that compare with 2023?.

Look, I'd say the short answer, Allen, is kind of what you're saying, we expect volumes or utilization to be very similar to 2023. Each provider is unique. We have a different base of business than what you might see at a macro level, especially related to some of the public providers.

We have projected low single-digit growth in cash collections, which as we said before, blends volume, acuity and mix throughout our customer base. So, low single-digits. Is there upside? We'll see, but we're pretty confident in our projections, just as we were in '23..

Great. Thank you. And then, Lee, I guess on strategy, it seems like there's now a greater focus on managed services and modular. Has that changed the way the salesforce is speaking with prospects in 2024? Thanks..

Yeah. Look, it's changed the way we think about prospective customers and I think the major change is -- and I'm glad you asked the question, Allen, I haven't articulated this is being very thoughtful about what customers we take on.

So, being thoughtful, if a customer has highly fragmented technologies, processes, systems, isn't centralized from a revenue cycle, that we are going to be very thoughtful on how we take those on. It doesn't mean we can't handle complexity, but we may project longer onboarding.

We may air towards managed services which has essentially let the customer keep control but deploy our AR coding other resources with global scale and technology and probably be more aggressive on deployment of Cloudmed, which drives one very important metric around revenue integrity, and that can help them with one of the bigger problem areas around denials and AR..

All right. Thank you so much. This closes our question-and-answer session for today. I'd now like to hand back over to Lee to close the session. Thank you..

Thank you, everyone. What I want to say in closing is we believe we've established a solid foundation for future growth and performance. We remain focused on opportunities ahead of us. As Jennifer articulated, one is delivering value for existing customers.

We want to really focus on customer satisfaction, deploying, continuing to expand our base business with our existing customers. Two is expanding our market position with new customers, including Providence and other new modular wins. Three is operational discipline and execution as we continue to expand our global footprint.

And fourth, and this is the part that you'll hear me and Jennifer talk about a lot more, is automation through technology with specific focus on AI. So, we are confident as we execute on these areas, we will deliver for our customers, first and foremost, and deliver sustainable growth, EBITDA and cash flow for our shareholders. Thank you..

This concludes today's conference call. You may now all disconnect. Thank you..