MEDNAX, INC. - 10-Q - Management's Discussion and Analysis of Financial Condition and Results of Operations - Insurance News | InsuranceNewsNet

InsuranceNewsNet — Your Industry. One Source.™

Sign in
  • Subscribe
  • About
  • Advertise
  • Contact
Home Now reading Newswires
Topics
    • Advisor News
    • Annuity Index
    • Annuity News
    • Companies
    • Earnings
    • Fiduciary
    • From the Field: Expert Insights
    • Health/Employee Benefits
    • Insurance & Financial Fraud
    • INN Magazine
    • Insiders Only
    • Life Insurance News
    • Newswires
    • Property and Casualty
    • Regulation News
    • Sponsored Articles
    • Washington Wire
    • Videos
    • ———
    • About
    • Meet our Editorial Staff
    • Advertise
    • Contact
    • Newsletters
  • Exclusives
  • NewsWires
  • Magazine
  • Newsletters
Sign in or register to be an INNsider.
  • AdvisorNews
  • Annuity News
  • Companies
  • Earnings
  • Fiduciary
  • Health/Employee Benefits
  • Insurance & Financial Fraud
  • INN Exclusives
  • INN Magazine
  • Insurtech
  • Life Insurance News
  • Newswires
  • Property and Casualty
  • Regulation News
  • Sponsored Articles
  • Video
  • Washington Wire
  • Life Insurance
  • Annuities
  • Advisor
  • Health/Benefits
  • Property & Casualty
  • Insurtech
  • About
  • Advertise
  • Contact
  • Editorial Staff

Get Social

  • Facebook
  • X
  • LinkedIn
Newswires
Newswires RSS Get our newsletter
Order Prints
April 28, 2022 Newswires
Share
Share
Post
Email

MEDNAX, INC. – 10-Q – Management's Discussion and Analysis of Financial Condition and Results of Operations

Edgar Glimpses

The following discussion highlights the principal factors that have affected our
financial condition and results of operations, as well as our liquidity and
capital resources, for the periods described. This discussion should be read in
conjunction with the unaudited Consolidated Financial Statements and the notes
thereto included in this Quarterly Report. In addition, reference is made to our
audited consolidated financial statements and notes thereto and related
Management's Discussion and Analysis of Financial Condition and Results of
Operations included in our Annual Report on Form 10-K for the fiscal year ended
December 31, 2021, filed with the Securities and Exchange Commission on February
17, 2022
(the "2021 Form 10-K"). As used in this Quarterly Report, the terms
"Mednax", the "Company", "we", "us" and "our" refer to the parent company,
Mednax, Inc., a Florida corporation, and the consolidated subsidiaries through
which its businesses are actually conducted (collectively, "MDX"), together with
MDX's affiliated business corporations or professional associations,
professional corporations, limited liability companies and partnerships
("affiliated professional contractors"). Certain subsidiaries of MDX have
contracts with our affiliated professional contractors, which are separate legal
entities that provide physician services in certain states and Puerto Rico. The
following discussion contains forward-looking statements. Please see the
Company's 2021 Form 10-K, including Item 1A, Risk Factors, for a discussion of
the uncertainties, risks and assumptions associated with these forward-looking
statements. In addition, please see "Caution Concerning Forward-Looking
Statements" below.

Overview

Mednax is a leading provider of physician services including newborn,
maternal-fetal, pediatric cardiology and other pediatric subspecialty care. Our
national network is comprised of affiliated physicians who provide clinical care
in 38 states and Puerto Rico. Our affiliated physicians provide neonatal
clinical care, primarily within hospital-based neonatal intensive care units
("NICUs"), to babies born prematurely or with medical complications; and
maternal-fetal and obstetrical medical care to expectant mothers experiencing
complicated pregnancies primarily in areas where our affiliated neonatal
physicians practice. Our network also includes other pediatric subspecialists,
including those who provide pediatric intensive care, pediatric cardiology care,
hospital-based pediatric care, pediatric surgical care, pediatric ear, nose and
throat, pediatric ophthalmology, pediatric urology services and pediatric
primary and urgent care.

Coronavirus Pandemic (COVID-19)

COVID-19 has had an impact on the demand for medical services provided by our
affiliated clinicians. Beginning in mid-March 2020, our affiliated office-based
practices, which specialize in maternal-fetal medicine, pediatric cardiology,
and numerous pediatric subspecialties, experienced a significant elevation of
appointment cancellations compared to historical normal levels. We believe
COVID-19, either directly or indirectly, also had an impact on our NICU patient
volumes. Overall, our operating results were significantly impacted by COVID-19
beginning in mid-March 2020, but volumes began to normalize in mid-2020 and
substantially recovered throughout 2020 with no material impacts from COVID-19
or its variants in 2021 or thus far in 2022. However, due to the continued
uncertainties surrounding the timeline of and impacts from COVID-19 and with
multiple variant strains still circulating, we are unable to predict the
ultimate impact on our business, financial condition, results of operations,
cash flows and the trading price of our securities at this time.

CARES Act

On March 27, 2020, the Coronavirus Aid, Relief, and Economic Security Act
("CARES Act") was signed into law. The CARES Act is a relief package intended to
assist many aspects of the American economy, including providing financial aid
to the healthcare industry to reimburse healthcare providers for lost revenue
and expenses attributable to COVID-19. The Department of Health and Human
Services
("HHS") is administering this program, and our affiliated physician
practices within continuing operations received an aggregate of $26.1 million in
relief payments during the year ended December 31, 2021 and $10.4 million during
the three months ended March 31, 2022.

General Economic Conditions and Other Factors

Our operations and performance depend significantly on economic conditions.
During the three months ended March 31, 2022, the percentage of our patient
service revenue being reimbursed under government-sponsored healthcare programs
("GHC Programs") decreased slightly as compared to the three months ended March
31, 2021
. We could, however, experience shifts toward GHC Programs if changes
occur in economic behaviors or population demographics within geographic
locations in which we provide services, including an increase in unemployment
and underemployment as well as losses of commercial health insurance or if there
are additional impacts from COVID-19 or its variants. Payments received from GHC
Programs are substantially less for equivalent services than payments received
from commercial insurance payors. In addition, costs of managed care premiums
and patient responsibility amounts continue to rise, and accordingly, we may
experience lower net revenue resulting from increased bad debt due to patients'
inability to pay for certain services.

Healthcare Reform

The Patient Protection and Affordable Care Act (the "ACA") contains a number of
provisions that have affected us and, absent amendment or repeal, may continue
to affect us over the next several years. These provisions include the
establishment of health insurance exchanges to facilitate the purchase of
qualified health plans, expanded Medicaid eligibility, subsidized insurance
premiums and additional requirements and incentives for businesses to provide
healthcare benefits. Other provisions have expanded the scope and reach of the
Federal Civil False Claims Act and other healthcare fraud and abuse laws.
Moreover, we could be affected by potential changes to various aspects of the
ACA, including changes to subsidies, healthcare insurance marketplaces and
Medicaid expansion.

                                       13

--------------------------------------------------------------------------------

Despite the ACA going into effect over a decade ago, continuous legal and
Congressional challenges to the law's provisions and persisting uncertainty with
respect to the scope and effect of certain provisions have made compliance
costly. In 2017, Congress unsuccessfully sought to replace substantial parts of
the ACA with different mechanisms for facilitating insurance coverage in the
commercial and Medicaid markets. Congress may again attempt to enact substantial
or target changes to the ACA in the future. Additionally, Centers for Medicare &
Medicaid Services
("CMS") has administratively revised a number of provisions
and may seek to advance additional significant changes through regulation,
guidance and enforcement in the future.

At the end of 2017, Congress repealed the part of the ACA that required most
individuals to purchase and maintain health insurance or face a tax penalty,
known as the individual mandate. In light of these changes, in December 2018, a
federal district court in Texas declared that key portions of the ACA were
inconsistent with the U.S. Constitution and that the entire ACA is invalid as a
result. Several states appealed this decision, and in December 2019, a federal
court of appeals upheld the district court's conclusion that part of the ACA is
unconstitutional but remanded for further evaluation whether in light of this
defect the entire ACA must be invalidated. Democratic attorneys general and the
House appealed the Fifth Circuit's decision to the Supreme Court. On March 2,
2020
, the Supreme Court agreed to hear the case, styled California v. Texas,
during the 2020-21 term. Oral arguments took place on November 2, 2020 and on
June 17, 2021, the Court held that the plaintiffs lacked standing to challenge
the ACA. Notwithstanding the Supreme Court's ruling, we cannot say for certain
whether there will be future challenges to the ACA or what impact, if any, such
challenges may have on our business. Changes resulting from these proceedings
could have a material impact on our business.

In late 2020 and early 2021, the results of the federal and state elections
changed which persons and parties occupy the Office of the President of the
United States and the U.S. Senate and many states' governors and legislatures.
The current Administration may propose sweeping changes to the U.S. healthcare
system, including expanding government-funded health insurance options,
additional Medicaid expansion or replacing current healthcare financing
mechanisms with systems that would be entirely administered by the federal
government. Any legislative or administrative change to the current healthcare
financing system could have a material adverse effect on our financial
condition, results of operations, cash flows and the trading price of our
securities.

In addition to the potential impacts to the ACA, there could be changes to other
GHC Programs, such as a change to the structure of Medicaid or Medicaid payment
rates set forth under state law. Historically, Congress and the Administration
have sought to convert Medicaid into a block grant or to institute per capita
spending caps, among other things. These changes, if implemented, could
eliminate the guarantee that everyone who is eligible and applies for benefits
would receive them and could potentially give states new authority to restrict
eligibility, cut benefits and make it more difficult for people to enroll.
Additionally, several states are considering and pursuing changes to their
Medicaid programs, such as requiring recipients to engage in employment or
education activities as a condition of eligibility for most adults, disenrolling
recipients for failure to pay a premium, or adjusting premium amounts based on
income. Many states have recently shifted a majority or all of their Medicaid
program beneficiaries into Managed Medicaid Plans. Managed Medicaid Plans have
some flexibility to set rates for providers, but many states require minimum
provider rates in their contracts with such plans. In July of each year, CMS
releases the annual Medicaid Managed Care Rate Development Guide which provides
federal baseline rules for setting reimbursement rates in managed care plans. We
could be affected by lower reimbursement rates in some of all of the Managed
Medicaid Plans with which we participate. We could also be materially impacted
if we are dropped from the provider network in one or more of the Managed
Medicaid Plans with which we currently participate.

We cannot predict with any assurance the ultimate effect of these laws and
resulting changes to payments under GHC Programs, nor can we provide any
assurance that they will not have a material adverse effect on our business,
financial condition, results of operations, cash flows and the trading price of
our securities. Further, any fiscal tightening impacting GHC Programs or changes
to the structure of any GHC Programs could have a material adverse effect on our
financial condition, results of operations, cash flows and the trading price of
our securities.

Medicaid Expansion

The ACA also allows states to expand their Medicaid programs through federal
payments that fund most of the cost of increasing the Medicaid eligibility
income limit from a state's historic eligibility levels to 133% of the federal
poverty level. To date, 38 states and the District of Columbia have expanded
Medicaid eligibility to cover this additional low-income patient population, and
other states are considering expansion. All of the states in which we operate,
however, already cover children in the first year of life and pregnant women if
their household income is at or below 133% of the federal poverty level.
Recently, Democrats in Congress have sought to expand Medicaid or Medicaid-like
coverage in states that have not yet expanded Medicaid. They also have sought to
reduce payments to certain hospitals in some of these states. Additionally, as
noted above, Congress is currently considering altering the terms and state
remuneration for Medicaid expansion pursuant to the ACA. Should any of these
changes take effect, we cannot predict with any assurance the ultimate effect to
reimbursements for our services.

"Surprise" Billing Legislation

In late 2020, Congress enacted legislation intended to protect patients from
"surprise" medical bills when services are furnished by providers who are not
subject to contractual arrangements and payment limitations with the patient's
insurer. Effective January 1, 2022, patients will be protected from unexpected
or "surprise" medical bills that could arise from out-of-network emergency care
provided at an out-of-network facility or at in-network facilities by
out-of-network providers and out-of-network nonemergency care provided at
in-network facilities without the patient's informed consent. Many states have
passed similar legislation, but the federal government has been working to enact
a ban on surprise billing for quite some time that pertains to ERISA health
insurance plans that are not addressed under state legislation.

Under the "No Surprises Act" ("NSA"), patients are only required to pay the
in-network cost-sharing amount, which has been determined through an established
regulatory formula and will count toward the patient's health plan deductible
and out-of-pocket cost-sharing limits. Providers will generally not be permitted
to balance bill patients beyond this cost-sharing amount. An out-of-network
provider will only

                                       14

--------------------------------------------------------------------------------

be permitted to bill a patient more than the in-network cost-sharing amount for
care if the provider gives the patient notice of the provider's network status
and delivers to the patient or their health plan an estimate of charges within
certain specified timeframes, and obtains the patient's written consent prior to
the delivery of care. Providers that violate these surprise billing prohibitions
may be subject to state enforcement action or federal civil monetary penalties.
Out of network providers can pursue recourse through an independent dispute
resolution ("IDR") process to determine payment amounts for out of network
services. These IDR results will bind both the provider and payor for a 90-day
period. The final rules implementing the NSA are currently being reviewed by the
Department of Health and Human Services, Department of Labor and Department of
Treasury
. In addition, certain IDR-related provisions of the NSA Interim Final
Rules are being challenged in courts by many provider groups, and the result of
this litigation may alter the NSA Interim Final Rules and the final rules that
are expected to be published later in 2022. Accordingly, we cannot predict how
these IDR results will compare to the rates that our affiliated physicians
customarily receive for their services.

These measures could limit the amount we can charge and recover for services we
furnish where we have not contracted with the patient's insurer, and therefore
could have a material adverse effect on our business, financial condition,
results of operations, cash flows and the trading price of our securities.
Moreover, these measures could affect our ability to contract with certain
payors and under historically similar terms and may cause, and the prospect of
these changes may have caused, payors to terminate their contracts with us and
our affiliated practices, further affecting our business, financial condition,
results of operations, cash flows and the trading price of our securities.

Non-GAAP Measures

In our analysis of our results of operations, we use certain non-GAAP financial
measures. We report adjusted earnings before interest, taxes and depreciation
and amortization from continuing operations, which is defined as income (loss)
from continuing operations before interest, income taxes, depreciation and
amortization, and transformational and restructuring related expenses. We also
report adjusted earnings per share ("Adjusted EPS") from continuing operations
which consists of diluted income (loss) from continuing operations per common
and common equivalent share adjusted for amortization expense, stock-based
compensation expense, transformational and restructuring related expenses and
any impacts from discrete tax events. For the three months ended March 31, 2022
and 2021, both Adjusted EBITDA and Adjusted EPS are being further adjusted to
exclude the impacts from the loss on the early extinguishment of debt.

We believe these measures, in addition to income (loss) from continuing
operations, net income (loss) and diluted net income (loss) from continuing
operations per common and common equivalent share, provide investors with useful
supplemental information to compare and understand our underlying business
trends and performance across reporting periods on a consistent basis. These
measures should be considered a supplement to, and not a substitute for,
financial performance measures determined in accordance with GAAP. In addition,
since these non-GAAP measures are not determined in accordance with GAAP, they
are susceptible to varying calculations and may not be comparable to other
similarly titled measures of other companies.

For a reconciliation of each of Adjusted EBITDA from continuing operations and
Adjusted EPS from continuing operations to the most directly comparable GAAP
measures for the three months ended March 31, 2022 and 2021, refer to the tables
below (in thousands, except per share data).


                                                              Three Months Ended
                                                                  March 31,
                                                            2022              2021

(Loss) income from continuing operations attributable
to Mednax, Inc.

                                         $     (20,941 )   $      5,352
Interest expense                                               11,818           17,645
Loss on early extinguishment of debt                           57,016           14,532
Income tax benefit                                             (7,401 )         (4,955 )
Depreciation and amortization expense                           8,769            8,031
Transformational and restructuring related expenses             1,421            4,878
Adjusted EBITDA from continuing operations
attributable to
  Mednax, Inc.                                          $      50,682     $     45,483



                                                           Three Months Ended
                                                                March 31,
                                                    2022                        2021
Weighted average diluted shares
outstanding                                        85,405                      85,491
(Loss) income from continuing operations
and diluted income from
  continuing operations per share
attributable to Mednax, Inc.               $ (20,941 )   $   (0.25 )   $   5,352     $    0.06
Adjustments (1):
Amortization (net of tax of $541 and
$890)                                          1,621          0.02         2,672          0.03
Stock-based compensation (net of tax of
$1,109 and $929)                               3,326          0.04         2,788          0.03
Transformational and restructuring
expenses (net of tax of
  $355 and $1,219)                             1,066          0.01         3,659          0.04
Loss on early extinguishment of debt
(net of tax of $14,254 and $3,633)            42,762          0.50        10,899          0.13
Net impact from discrete tax events              492          0.01        (5,067 )       (0.05 )
Adjusted income and diluted EPS from
continuing operations
  attributable to Mednax, Inc.             $  28,326     $    0.33     $  20,303     $    0.24



                                       15

--------------------------------------------------------------------------------

(1)

A blended tax rate of 25% was used to calculate the tax effects of the
adjustments for the three months ended March 31, 2022 and 2021.

Results of Operations

Three Months Ended March 31, 2022 as Compared to Three Months Ended March 31,

                                      2021

Our net revenue attributable to continuing operations was $482.2 million for the
three months ended March 31, 2022, as compared to $446.8 million for the same
period in 2021. The increase in revenue of $35.4 million, or 7.9%, was primarily
attributable to increases in revenue from net acquisitions and to a lesser
extent growth in same-unit revenue. Same units are those units at which we
provided services for the entire current period and the entire comparable
period. Same-unit net revenue increased by $5.6 million, or 1.3%. The increase
in same-unit net revenue was comprised of an increase of $14.2 million, or 3.2%,
related to patient service volumes, partially offset by a decrease of $8.6
million
, or 1.9%, from net reimbursement-related factors. The increase in
revenue from patient service volumes was related to increases across all of our
hospital-based and office-based women's and children's services. The net
decrease in revenue related to net reimbursement-related factors was primarily
due to a decrease in revenue resulting from certain revenue cycle management
transition activities, partially offset by increases in revenue from CARES Act
relief and contract and administrative fees received from our hospital partners.

Practice salaries and benefits attributable to continuing operations increased
$24.2 million, or 7.6%, to $343.2 million for the three months ended March 31,
2022
, as compared to $319.0 million for the same period in 2021. Of the $24.2
million
increase, $19.3 million was related to salaries which primarily
reflected increases in clinician compensation expense and $4.9 million was
related to benefits and incentive compensation.

Practice supplies and other operating expenses attributable to continuing
operations increased $6.3 million, or 28.3%, to $28.5 million for the three
months ended March 31, 2022, as compared to $22.2 million for the same period in
2021. The increase was primarily attributable to practice supply, rent and other
costs related to our acquisitions and to a lesser extent net increases at our
existing units.

General and administrative expenses attributable to continuing operations
primarily include all billing and collection functions and all other salaries,
benefits, supplies and operating expenses not specifically related to the
day-to-day operations of our affiliated physician practices and services.
General and administrative expenses were $61.3 million for the three months
ended March 31, 2022, as compared to $66.5 million for the same period in 2021.
The net decrease of $5.2 million is primarily related to lower professional
fees, including legal fees, as well as a net savings in revenue cycle management
expenses. General and administrative expenses as a percentage of net revenue was
12.7% for the three months ended March 31, 2022, as compared to 14.9% for the
same period in 2021.

Transformational and restructuring related expenses attributable to continuing
operations were $1.4 million for the three months ended March 31, 2022, as
compared to $4.9 million for the same period in 2021. The decrease of $3.5
million
reflects the continued reduction in the scope of activities with the
expenses during the first quarter of 2022 primarily for position eliminations.

Depreciation and amortization expense attributable to continuing operations was
$8.8 million for the three months ended March 31, 2022, as compared to $8.0
million
for the same period in 2021. The net increase of $0.8 million was
primarily related to an increase in depreciation expense for new information
technology equipment, partially offset by lower amortization expense related to
intangible assets.

Income from operations attributable to continuing operations increased $13.0
million
, or 49.8%, to $39.1 million for the three months ended March 31, 2022,
as compared to $26.1 million for the same period in 2021. Our operating margin
was 8.1% for the three months ended March 31, 2022, as compared to 5.8% for the
same period in 2021. The increase in our operating margin was primarily due to
higher acquisition and organic related revenue growth, CARES Act relief and net
decreases in overall operating expenses. Excluding transformation and
restructuring related expenses, our income from operations attributable to
continuing operations was $40.5 million and $31.0 million, and our operating
margin was 8.4% and 6.9% for the three months ended March 31, 2022 and 2021,
respectively. We believe excluding the impacts from the transformational and
restructuring related activity provides a more comparable view of our operating
income and operating margin from continuing operations.

Total non-operating expenses attributable to continuing operations were $67.5
million
for the three months ended March 31, 2022, as compared to $25.7 million
for the same period in 2021. The net increase in non-operating expenses was
primarily related to the $57.0 million loss on early extinguishment of debt
resulting from the redemption of our 6.25% senior unsecured notes due 2027 (the
"2027 Notes") in February 2022 and interest expense related to a new issuance of
5.375% senior unsecured notes due 2030 (the "2030 Notes"), partially offset by a
decrease in interest expense related to the 2027 Notes.

Our effective income tax rate attributable to continuing operations ("tax rate")
was 26.1% for the three months ended March 31, 2022 and was not meaningful for
three months ended March 31, 2021. The first quarter 2021 tax rate was impacted
primarily by a discrete tax benefit of $7.1 million related to a change in
estimate for the 2020 net operating loss carryback as allowed under the CARES
Act for refund at the 35% federal rate. After excluding discrete tax impacts,
during the three months ended March 31, 2022 and 2021, our effective income tax
rate was 27.9% and 28.2%, respectively. We believe excluding discrete tax
impacts provides a more comparable view of our tax rate.

Loss from continuing operations attributable to Mednax, Inc. was $20.9 million
for the three months ended March 31, 2022, driven by the loss on early
extinguishment of debt, as compared to income of $5.4 million for the same
period in 2021. Adjusted EBITDA from continuing operations attributable to
Mednax, Inc. was $50.7 million for the three months ended March 31, 2022, as
compared to $45.5 million for the same period in 2021.


                                       16

--------------------------------------------------------------------------------

Diluted loss from continuing operations per common and common equivalent share
attributable to Mednax, Inc. was $0.25 on weighted average shares outstanding of
85.4 million for the three months ended March 31, 2022, as compared to diluted
net income of $0.06 on weighted average shares outstanding of 85.5 million for
the same period in 2021. Adjusted EPS from continuing operations was $0.33 for
the three months ended March 31, 2022, as compared to $0.24 for the same period
in 2021.

Loss from discontinued operations, net of tax, was $0.2 million for the three
months ended March 31, 2022, as compared to income of $12.3 million for the same
period in 2021. Diluted loss from discontinued operations per common and common
equivalent share was nominal for the three months ended March 31, 2022, as
compared to diluted net income of $0.15 for the three months ended March 31,
2021
.

Net loss attributable to Mednax, Inc. was $21.2 million for the three months
ended March 31, 2022, as compared to income of $17.6 million for the same period
in 2021. Diluted net loss per common and common equivalent share attributable to
Mednax, Inc. was $0.25 for the three months ended March 31, 2022, as compared to
diluted net income of $0.21 for the same period in 2021.

Liquidity and Capital Resources

As of March 31, 2022, we had $7.2 million of cash and cash equivalents
attributable to continuing operations as compared to $387.4 billion at December
31, 2021
. Additionally, we had working capital attributable to continuing
operations of $170.1 million at March 31, 2022, a decrease of $243.1 million
from working capital of $413.2 billion at December 31, 2021. The net decrease in
working capital is primarily due to the redemption of the 2027 Notes in February
2022
.

Cash Flows from Continuing Operations

Cash used in operating, investing and financing activities from continuing
operations is summarized as follows (in thousands):

                          Three Months Ended
                               March 31,
                          2022           2021
Operating activities   $  (89,931 )   $  (98,926 )
Investing activities      (26,273 )      (12,714 )
Financing activities     (256,457 )     (761,661 )


Operating Activities from Continuing Operations

During the three months ended March 31, 2022, our net cash used in operating
activities for continuing operations was $89.9 million, compared to $98.9
million
for the same period in 2021. The net decrease in cash used of $9.0
million
was primarily due to a decrease in cash flow due to lower earnings,
changes in accounts payable and accrued expenses, primarily related to higher
incentive compensation payments, and increases in cash used for prepaid
expenses, other assets and accounts receivable, partially offset by increases in
cash flow from income taxes, deferred income taxes and other liabilities.

During the three months ended March 31, 2022, cash flow from accounts receivable
for continuing operations decreased by $20.2 million, as compared to $11.6
million
for the same period in 2021. The decrease in cash flow from accounts
receivable for the three months ended March 31, 2022 was primarily due to
increases in ending accounts receivable balances at existing units due to timing
of revenue cycle management activities.

Days sales outstanding ("DSO") is one of the key factors that we use to evaluate
the condition of our accounts receivable and the related allowances for
contractual adjustments and uncollectibles. DSO reflects the timeliness of cash
collections on billed revenue and the level of reserves on outstanding accounts
receivable. Our DSO for continuing operations was 59.2 days at March 31, 2022 as
compared to 55.2 days at December 31, 2021. The increase in our DSO primarily
related to the timing of cash collections at our existing units.

Investing Activities from Continuing Operations

During the three months ended March 31, 2022, our net cash used in investing
activities for continuing operations of $26.3 million consisted of acquisitions
payments of $25.7 million and capital expenditures of $7.1 million, partially
offset by net proceeds from maturities and sales of investments of $6.4 million.

Financing Activities from Continuing Operations

During the three months ended March 31, 2022, our net cash used in financing
activities for continuing operations of $256.5 million primarily consisted of
$1.05 billion related to the redemption of the 2027 Notes, including the call
premium, payments for financing costs of $7.9 million and the repurchase of $1.2
million
of our common stock, partially offset by $400.0 million in proceeds from
the issuance of the 2030 Notes, $250.0 million from our new term loan and net
borrowings on our revolving line of credit of $149.0 million.

Liquidity

On February 11, 2022, we issued $400.0 million of 5.375% unsecured senior notes
due 2030 (the "2030 Notes"). We used the net proceeds from the issuance of the
2030 Notes, together with $100.0 million drawn under our Revolving Credit Line
(as defined below), $250.0 million of Term A Loan (as defined below) and
approximately $308.0 million of cash on hand, to redeem (the "Redemption") the
2027 Notes,

                                       17

--------------------------------------------------------------------------------

which had an outstanding principal balance of $1.0 billion, and to pay costs,
fees and expenses associated with the Redemption and the Credit Agreement
Amendment (as defined below).

Also in connection with the Redemption, we amended and restated the Credit
Agreement (the "Credit Agreement Amendment") concurrently with the issuance of
the 2030 Notes. The Credit Agreement, as amended by the Credit Agreement
Amendment (the "Amended Credit Agreement"), among other things, (i) refinanced
the prior unsecured revolving credit facility with a $450.0 million unsecured
revolving credit facility, including a $37.5 million sub-facility for the
issuance of letters of credit (the "Revolving Credit Line"), and a new $250.0
million
term A loan facility ("Term A Loan") and (ii) removed JPMorgan Chase
Bank, N.A
., as the administrative agent under the Credit Agreement and appointed
Bank of America, N.A. as the administrative agent for the lenders under the
Amended Credit Agreement.

The Amended Credit Agreement matures on February 11, 2027 and is guaranteed on
an unsecured basis by substantially all of our subsidiaries and affiliated
professional contractors. At our option, borrowings under the Amended Credit
Agreement bear interest at (i) the Alternate Base Rate (defined as the highest
of (a) the prime rate as announced by Bank of America, N.A., (b) the Federal
Funds Rate plus 0.50% and (c) Term Secured Overnight Financing Rate ("SOFR") for
an interest period of one month plus 1.00% with a 1.00% floor) plus an
applicable margin rate of 0.50% for the first two fiscal quarters after the date
of the Credit Agreement Amendment, and thereafter at an applicable margin rate
ranging from 0.125% to 0.750% based on our consolidated net leverage ratio or
(ii) Term SOFR rate (calculated as the Secured Overnight Financing Rate
published on the applicable Reuters screen page plus a spread adjustment of
0.10%, 0.15% or 0.25% depending on if we select a one-month, three-month or
six-month interest period, respectively, for the applicable loan with a 0%
floor), plus an applicable margin rate of 1.50% for the first two full fiscal
quarters after the date of the Credit Agreement Amendment, and thereafter at an
applicable margin rate ranging from 1.125% to 1.750% based on our consolidated
net leverage ratio. The Amended Credit Agreement also provides for other
customary fees and charges, including an unused commitment fee with respect to
the Revolving Credit Line ranging from 0.150% to 0.200% of the unused lending
commitments under the Revolving Credit Line, based on our consolidated net
leverage ratio.

The Amended Credit Agreement contains customary covenants and restrictions,
including covenants that require us to maintain a minimum interest coverage
ratio, a maximum consolidated total consolidated net leverage ratio and to
comply with laws, and restrictions on the ability to pay dividends, incur
indebtedness or liens and make certain other distributions subject to baskets
and exceptions, in each case, as specified therein. Failure to comply with these
covenants would constitute an event of default under the Amended Credit
Agreement, notwithstanding the ability of the company to meet its debt service
obligations. The Amended Credit Agreement includes various customary remedies
for the lenders following an event of default, including the acceleration of
repayment of outstanding amounts under the Amended Credit Agreement. In
addition, we may increase the principal amount of the Revolving Credit Line or
incur additional term loans under the Amended Credit Agreement in an aggregate
principal amount such that on a pro forma basis after giving effect to such
increase or additional term loans, we are in compliance with the financial
covenants, subject to the satisfaction of specified conditions and additional
caps in the event that the Amended Credit Agreement is secured.

During the three months ended March 31, 2022, in connection with the redemption
of our 2027 Notes and the Credit Agreement Amendment, we recognized a loss on
early extinguishment of debt of $57.0 million, which primarily included cash
premiums on the 2027 Notes and accelerated amortization of deferred financing
costs.

At March 31, 2022, we had an outstanding principal balance on the Amended Credit
Agreement of $399.0 million, composed of $149.0 million under the Revolving
Credit Line and $250.0 million under the Term A Loan. We had $301.0 million
available on the Amended Credit Agreement at March 31, 2022.

At March 31, 2022, we had an outstanding principal balance of $400.0 million on
the 2030 Notes. Our obligations under the 2030 Notes are guaranteed on an
unsecured senior basis by the same subsidiaries and affiliated professional
contractors that guarantee our Amended Credit Agreement. Interest on the 2030
Notes accrues at the rate of 5.375% per annum, or $21.5 million, and is payable
semi-annually in arrears on February 15 and August 15, beginning on August 15,
2022
.

The indenture under which the 2030 Notes are issued, among other things, limits
our ability to (1) incur liens and (2) enter into sale and lease-back
transactions, and also limits our ability to merge or dispose of all or
substantially all of our assets, in all cases, subject to a number of customary
exceptions. Although we are not required to make mandatory redemption or sinking
fund payments with respect to the 2030 Notes, upon the occurrence of a change in
control, we may be required to repurchase the 2030 Notes at a purchase price
equal to 101% of the aggregate principal amount of the 2030 Notes repurchased
plus accrued and unpaid interest.

At March 31, 2022, we believe we were in compliance, in all material respects,
with the financial covenants and other restrictions applicable to us under the
Amended Credit Agreement and the 2030 Notes. We believe we will be in compliance
with these covenants throughout 2022.

We maintain professional liability insurance policies with third-party insurers,
subject to self-insured retention, exclusions and other restrictions. We
self-insure our liabilities to pay self-insured retention amounts under our
professional liability insurance coverage through a wholly owned captive
insurance subsidiary. We record liabilities for self-insured amounts and claims
incurred but not reported based on an actuarial valuation using historical loss
information, claim emergence patterns and various actuarial assumptions. Our
total liability related to professional liability risks at March 31, 2022 was
$299.1 million, of which $34.0 million is classified as a current liability
within accounts payable and accrued expenses in the Consolidated Balance Sheet.
In addition, there is a corresponding insurance receivable of $54.9 million
recorded as a component of other assets for certain professional liability
claims that are covered by insurance policies.

We anticipate that funds generated from operations, together with our current
cash on hand and funds available under our Amended Credit Agreement, will be
sufficient to finance our working capital requirements, fund anticipated
acquisitions and capital expenditures, fund

                                       18

--------------------------------------------------------------------------------

expenses related to our transformational and restructuring activities, fund our
share repurchase programs and meet our contractual obligations for at least the
next 12 months from the date of issuance of this Quarterly Report on Form 10-Q.

Caution Concerning Forward-Looking Statements

Certain information included or incorporated by reference in this Quarterly
Report may be deemed to be "forward-looking statements" within the meaning of
the Private Securities Litigation Reform Act of 1995, Section 27A of the
Securities Act of 1933, as amended, and Section 21E of the Securities Exchange
Act of 1934, as amended (the "Exchange Act"). Forward-looking statements may
include, but are not limited to, statements relating to our objectives, plans
and strategies, and all statements, other than statements of historical facts,
that address activities, events or developments that we intend, expect, project,
believe or anticipate will or may occur in the future are forward-looking
statements. These statements are often characterized by terminology such as
"believe," "hope," "may," "anticipate," "should," "intend," "plan," "will,"
"expect," "estimate," "project," "positioned," "strategy" and similar
expressions, and are based on assumptions and assessments made by our management
in light of their experience and their perception of historical trends, current
conditions, expected future developments and other factors they believe to be
appropriate. Any forward-looking statements in this Quarterly Report are made as
of the date hereof, and we undertake no duty to update or revise any such
statements, whether as a result of new information, future events or otherwise.
Forward-looking statements are not guarantees of future performance and are
subject to risks and uncertainties. Important factors that could cause actual
results, developments and business decisions to differ materially from
forward-looking statements are described in the 2021 Form 10-K, including the
section entitled "Risk Factors."


                                       19

--------------------------------------------------------------------------------

Older

Aircastle Announces Fourth Quarter and Full Year 2021 Results

Newer

KindHealth Insurance Discovery Platform Helps Consumers Find Insurance That Provides Care and Financial Security

Advisor News

  • When new investment trends emerge, Gen Z is most likely generation to be first in
  • Could ‘plain English’ become an advisor’s secret weapon?
  • IRI urges Senate action on 403(b) parity legislation
  • Three estate planning ideas to protect your clients and their wealth
  • What advisors must know about accessible client documents
More Advisor News

Annuity News

  • NUNN INTRODUCES BILL TO CUT RED TAPE, GIVE IOWANS CLEARER INSURANCE INFORMATION
  • NAIC working group pressed to accelerate annuity illustration overhaul
  • State Auditor James Brown Kicks Off Life Insurance Awareness Month With Policy Locator Tool
  • Wink: Annuity sales post strong Q2, led by MYGAs and structured products
  • Legacy Marketing Group partners with Malibu Life USA for annuity launch
More Annuity News

Health/Employee Benefits News

  • An Application for the Trademark “UHCCARECONNECT” Has Been Filed by UnitedHealth Group Incorporated: UnitedHealth Group Incorporated
  • Findings from University of Colorado Anschutz in Hypertension Provides New Insights (Blood Pressure Control Among Adherent vs Nonadherent Medicare Patients With Hypertension): Cardiovascular Diseases and Conditions – Hypertension
  • DeKalb County employees will still have insured access to GLP-1s
  • New York approves small, individual insurance plan rate hikes for 2027
  • AM Best Affirms Credit Ratings of Ping An Health Insurance Company of China, Ltd.
Sponsor
More Health/Employee Benefits News

Life Insurance News

  • AM Best Affirms Credit Ratings of Zurich Insurance Group Ltd and Its Main Rated Subsidiaries
  • Best’s Market Segment Report: AM Best Maintains Stable Outlook on China’s Non-Life Insurance Segment
  • Understanding Nonequity Split-Dollar
  • Life insurance loans: what to do when a client shows interest in one
  • Do You Qualify for Any of September's Class Action Settlements?
Sponsor
More Life Insurance News

NEWS INSIDE

  • Companies
  • Earnings
  • Economic News
  • INN Magazine
  • Insurtech News
  • Newswires Feed
  • Regulation News
  • Washington Wire
  • Videos

FEATURED OFFERS

Press Releases

  • Classic Car Insurer OpenRoad Insurance Expands to 40 U.S. States in Two Years
  • How Aspire General Turned an Early Technology Bet Into Claims Automation at Scale with Kyber
  • Adjusto launches AI-Native contents claims services powered by its technology platform
  • URL Insurance Group Celebrates 40 Years of Service, Growth, and Industry Leadership
  • MassMutual Ascend Surpasses $2 Billion in Lifetime Advisory Annuity Sales, Reflecting Continued Momentum in RIA Channel
More Press Releases > Add Your Press Release >

How to Write For InsuranceNewsNet

Find out how you can submit content for publishing on our website.
View Guidelines

Topics

  • Advisor News
  • Annuity Index
  • Annuity News
  • Companies
  • Earnings
  • Fiduciary
  • From the Field: Expert Insights
  • Health/Employee Benefits
  • Insurance & Financial Fraud
  • INN Magazine
  • Insiders Only
  • Life Insurance News
  • Newswires
  • Property and Casualty
  • Regulation News
  • Sponsored Articles
  • Washington Wire
  • Videos
  • ———
  • About
  • Meet our Editorial Staff
  • Advertise
  • Contact
  • Newsletters

Top Sections

  • AdvisorNews
  • Annuity News
  • Health/Employee Benefits News
  • InsuranceNewsNet Magazine
  • Life Insurance News
  • Property and Casualty News
  • Washington Wire

Our Company

  • About
  • Advertise
  • Contact
  • Meet our Editorial Staff
  • Magazine Subscription
  • Write for INN

Sign up for our FREE e-Newsletter!

Get breaking news, exclusive stories, and money- making insights straight into your inbox.

select Newsletter Options
Facebook Linkedin Twitter
© 2026 InsuranceNewsNet.com, Inc. All rights reserved.
  • Terms & Conditions
  • Privacy Policy
  • InsuranceNewsNet Magazine

Sign in with your Insider Pro Account

Not registered? Become an Insider Pro.