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Revenue Recognition and Accounts Receivable Revenue Recognition Segment Revenue by Payor (Details) - USD ($) $ in Thousands | 3 Months Ended | 12 Months Ended
--- | --- | ---
Dec. 31, 2018 | Sep. 30, 2018 | Jun. 30, 2018 | Mar. 31, 2018 | Dec. 31, 2017 | Sep. 30, 2017 | Jun. 30, 2017 | Mar. 31, 2017 | Dec. 31, 2018 | Dec. 31, 2017 | Dec. 31, 2016
Disaggregation of Revenue [Line Items] |  |  |  |  |  |  |  |  |  |  |
Patient service revenues |  |  |  |  |  |  |  |  | $ 10,709,981 | $ 10,093,670 | $ 9,727,360
Other revenues |  |  |  |  |  |  |  |  | 744,457 | 1,268,328 | 1,411,411
Total revenues | $ 2,821,124 | $ 2,847,330 | $ 2,886,953 | $ 2,849,444 | $ 2,780,913 | $ 2,765,071 | $ 2,699,399 | $ 2,631,251 | 11,404,851 | 10,876,634 | 10,707,467
Intersegment Elimination |  |  |  |  |  |  |  |  |  |  |
Disaggregation of Revenue [Line Items] |  |  |  |  |  |  |  |  |  |  |
Total revenues |  |  |  |  |  |  |  |  | (127,186) | (79,779) | (52,094)
Medicare and Medicare Advantage |  |  |  |  |  |  |  |  |  |  |
Disaggregation of Revenue [Line Items] |  |  |  |  |  |  |  |  |  |  |
Patient service revenues |  |  |  |  |  |  |  |  | 6,063,891 | 5,253,012 | 5,303,718
Other revenues |  |  |  |  |  |  |  |  | 492,812 | 902,289 | 974,146
Medicaid and Managed Medicaid |  |  |  |  |  |  |  |  |  |  |
Disaggregation of Revenue [Line Items] |  |  |  |  |  |  |  |  |  |  |
Patient service revenues |  |  |  |  |  |  |  |  | 628,766 | 606,827 | 319,553
Other revenues |  |  |  |  |  |  |  |  | 44,246 | 71,426 | 82,428
Other Government Payors |  |  |  |  |  |  |  |  |  |  |
Disaggregation of Revenue [Line Items] |  |  |  |  |  |  |  |  |  |  |
Patient service revenues |  |  |  |  |  |  |  |  | 782,593 | 622,218 | 308,400
Commercial Payors |  |  |  |  |  |  |  |  |  |  |
Disaggregation of Revenue [Line Items] |  |  |  |  |  |  |  |  |  |  |
Patient service revenues |  |  |  |  |  |  |  |  | 3,278,094 | 3,181,425 | 3,391,740
Other revenues |  |  |  |  |  |  |  |  | 90,890 | 116,503 | 128,824
Other |  |  |  |  |  |  |  |  |  |  |
Disaggregation of Revenue [Line Items] |  |  |  |  |  |  |  |  |  |  |
Other revenues |  |  |  |  |  |  |  |  | 150,745 | 202,713 | 250,752
U.S. dialysis and related lab services |  |  |  |  |  |  |  |  |  |  |
Disaggregation of Revenue [Line Items] |  |  |  |  |  |  |  |  |  |  |
Total revenues |  |  |  |  |  |  |  |  | 10,242,999 | 9,304,889 | 9,110,834
U.S. dialysis and related lab services | Intersegment Elimination |  |  |  |  |  |  |  |  |  |  |
Disaggregation of Revenue [Line Items] |  |  |  |  |  |  |  |  |  |  |
Total revenues |  |  |  |  |  |  |  |  | (92,950) | (55,176) | (27,355)
U.S. dialysis and related lab services | Medicare and Medicare Advantage |  |  |  |  |  |  |  |  |  |  |
Disaggregation of Revenue [Line Items] |  |  |  |  |  |  |  |  |  |  |
Patient service revenues |  |  |  |  |  |  |  |  | 6,063,891 | 5,253,012 | 5,303,718
Other revenues |  |  |  |  |  |  |  |  | 0 | 0 | 0
U.S. dialysis and related lab services | Medicaid and Managed Medicaid |  |  |  |  |  |  |  |  |  |  |
Disaggregation of Revenue [Line Items] |  |  |  |  |  |  |  |  |  |  |
Patient service revenues |  |  |  |  |  |  |  |  | 628,766 | 606,827 | 319,553
Other revenues |  |  |  |  |  |  |  |  | 0 | 0 | 0
U.S. dialysis and related lab services | Other Government Payors |  |  |  |  |  |  |  |  |  |  |
Disaggregation of Revenue [Line Items] |  |  |  |  |  |  |  |  |  |  |
Patient service revenues |  |  |  |  |  |  |  |  | 446,999 | 362,567 | 143,207
U.S. dialysis and related lab services | Commercial Payors |  |  |  |  |  |  |  |  |  |  |
Disaggregation of Revenue [Line Items] |  |  |  |  |  |  |  |  |  |  |
Patient service revenues |  |  |  |  |  |  |  |  | 3,176,413 | 3,117,920 | 3,355,066
Other revenues |  |  |  |  |  |  |  |  | 0 | 0 | 0
U.S. dialysis and related lab services | Other |  |  |  |  |  |  |  |  |  |  |
Disaggregation of Revenue [Line Items] |  |  |  |  |  |  |  |  |  |  |
Other revenues |  |  |  |  |  |  |  |  | 19,880 | 19,739 | 16,645
Other ancillary services and strategic initiatives |  |  |  |  |  |  |  |  |  |  |
Disaggregation of Revenue [Line Items] |  |  |  |  |  |  |  |  |  |  |
Total revenues |  |  |  |  |  |  |  |  | 1,161,852 | 1,571,745 | 1,596,633
Other ancillary services and strategic initiatives | Intersegment Elimination |  |  |  |  |  |  |  |  |  |  |
Disaggregation of Revenue [Line Items] |  |  |  |  |  |  |  |  |  |  |
Total revenues |  |  |  |  |  |  |  |  | (34,236) | (24,603) | (24,739)
Other ancillary services and strategic initiatives | Medicare and Medicare Advantage |  |  |  |  |  |  |  |  |  |  |
Disaggregation of Revenue [Line Items] |  |  |  |  |  |  |  |  |  |  |
Patient service revenues |  |  |  |  |  |  |  |  | 0 | 0 | 0
Other revenues |  |  |  |  |  |  |  |  | 492,812 | 902,289 | 974,146
Other ancillary services and strategic initiatives | Medicaid and Managed Medicaid |  |  |  |  |  |  |  |  |  |  |
Disaggregation of Revenue [Line Items] |  |  |  |  |  |  |  |  |  |  |
Patient service revenues |  |  |  |  |  |  |  |  | 0 | 0 | 0
Other revenues |  |  |  |  |  |  |  |  | 44,246 | 71,426 | 82,428
Other ancillary services and strategic initiatives | Other Government Payors |  |  |  |  |  |  |  |  |  |  |
Disaggregation of Revenue [Line Items] |  |  |  |  |  |  |  |  |  |  |
Patient service revenues |  |  |  |  |  |  |  |  | 335,594 | 259,651 | 165,193
Other ancillary services and strategic initiatives | Commercial Payors |  |  |  |  |  |  |  |  |  |  |
Disaggregation of Revenue [Line Items] |  |  |  |  |  |  |  |  |  |  |
Patient service revenues |  |  |  |  |  |  |  |  | 101,681 | 63,505 | 36,674
Other revenues |  |  |  |  |  |  |  |  | 90,890 | 116,503 | 128,824
Other ancillary services and strategic initiatives | Other |  |  |  |  |  |  |  |  |  |  |
Disaggregation of Revenue [Line Items] |  |  |  |  |  |  |  |  |  |  |
Other revenues |  |  |  |  |  |  |  |  | $ 130,865 | $ 182,974 | $ 234,107

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