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Revenue
 12 Months Ended
Dec. 31, 2021
Revenue From Contract With Customer [Abstract]  
Revenue

4. Revenue

Revenue is primarily derived from services rendered to patients for inpatient psychiatric and substance abuse care, outpatient psychiatric care and residential treatment. The services provided by the Company have no fixed duration and can be terminated by the patient or the facility at any time, and therefore, each treatment is its own stand-alone contract.

Services ordered by a healthcare provider in an episode of care are not separately identifiable and therefore have been combined into a single performance obligation for each contract. The Company recognizes revenue as its performance obligations are completed. The performance obligation is satisfied over time as the customer simultaneously receives and consumes the benefits of the healthcare services provided. For inpatient services, the Company recognizes revenue equally over the patient stay on a daily basis. For outpatient services, the Company recognizes revenue equally over the number of treatments provided in a single episode of care. Typically, patients and third-party payors are billed within several days of the service being performed or the patient being discharged, and payments are due based on contract terms.

As the Company’s performance obligations relate to contracts with a duration of one year or less, the Company elected the optional exemption in ASC 606-10-50-14(a). Therefore, the Company is not required to disclose the transaction price for the remaining performance obligations at the end of the reporting period or when the Company expects to recognize the revenue. The Company has minimal unsatisfied performance obligations at the end of the reporting period as the Company’s patients typically are under no obligation to remain admitted in the Company’s facilities.

At December 31, 2021 and 2020, estimated implicit price concessions of $49.7 million and $62.1 million, respectively, had been recorded as reductions to the Company’s accounts receivable balances to enable the Company to record its revenues and accounts receivable at the estimated amounts the Company expected to collect. The adoption of ASU 2014-09 did not have a significant impact on the Company’s consolidated statements of operations.

The Company disaggregates revenue from contracts with customers by service type and by payor.

The Company’s facilities and services provided by the facilities can generally be classified into the following categories: acute inpatient psychiatric facilities; specialty treatment facilities; and residential treatment centers.

Acute inpatient psychiatric facilities. Acute inpatient psychiatric facilities provide a high level of care in order to stabilize patients that are either a threat to themselves or to others. The acute setting provides 24-hour observation, daily intervention and monitoring by psychiatrists.

Specialty treatment facilities. Specialty treatment facilities include residential recovery facilities, eating disorder facilities and comprehensive treatment centers. The Company provides a comprehensive continuum of care for adults with addictive disorders and co-occurring mental disorders. Inpatient, including detoxification and rehabilitation, partial hospitalization and outpatient treatment programs give patients access to the least restrictive level of care.

Residential treatment centers. Residential treatment centers treat patients with behavioral disorders in a non-hospital setting, including outdoor programs. The facilities balance therapy activities with social, academic and other activities.

The table below presents total U.S. revenue attributed to each category (in thousands):

 

 

 

Year Ended December 31,

 

 

 

2021

 

 

2020

 

 

2019

 

Acute inpatient psychiatric facilities

 

$

1,126,872

 

 

$

984,609

 

 

$

912,097

 

Specialty treatment facilities

 

 

896,564

 

 

 

802,022

 

 

 

788,232

 

Residential treatment centers

 

 

283,169

 

 

 

281,158

 

 

 

286,959

 

Other

 

 

7,789

 

 

 

22,140

 

 

 

21,093

 

Revenue

 

$

2,314,394

 

 

$

2,089,929

 

 

$

2,008,381

 

 

The Company receives payments from the following sources for services rendered in its facilities: (i) state governments under their respective Medicaid and other programs; (ii) commercial insurers; (iii) the federal government under the Medicare program administered by the Centers for Medicare and Medicaid Services (“CMS”); and (iv) individual patients and clients.

The Company determines the transaction price based on established billing rates reduced by contractual adjustments provided to third-party payors, discounts provided to uninsured patients and implicit price concessions. Contractual adjustments and discounts are based on contractual agreements, discount policies and historical experience. Implicit price concessions are based on historical collection experience. Most of the Company’s facilities have contracts containing variable consideration. However, it is unlikely a significant reversal of revenue will occur when the uncertainty is resolved, and therefore, the Company has included the variable consideration in the estimated transaction price. Subsequent changes resulting from a patient’s ability to pay are recorded as bad debt expense, which is included as a component of other operating expenses in the consolidated statements of operations. Bad debt expense for the years ended December 31, 2021, 2020 and 2019 was not significant.

The Company derives a significant portion of its revenue from Medicare, Medicaid and other payors that receive discounts from established billing rates. The Medicare and Medicaid regulations and various managed care contracts under which these discounts must be estimated are complex, subject to interpretation and adjustment, and may include multiple reimbursement mechanisms for different types of services provided in the Company’s facilities and cost settlement provisions. Management estimates the transaction price on a payor-specific basis given its interpretation of the applicable regulations or contract terms. The services authorized and provided and related reimbursement are often subject to interpretation that could result in payments that differ from the Company’s estimates. Additionally, updated regulations and contract renegotiations occur frequently, necessitating regular review and assessment of the estimation process by management.

Settlements under cost reimbursement agreements with third-party payors are estimated and recorded in the period in which the related services are rendered and are adjusted in future periods as final settlements are determined. Final determination of amounts earned under the Medicare and Medicaid programs often occurs in subsequent years because of audits by such programs, rights of appeal and the application of numerous technical provisions. In the opinion of management, adequate provision has been made for any adjustments and final settlements. However, there can be no assurance that any such adjustments and final settlements will not have a material effect on the Company’s financial condition or results of operations. The Company’s cost report payables were $6.5 million for the year ended December 31, 2021 and were included in other current liabilities on the consolidated balance sheet. The Company’s cost report receivables were $5.8 million for the year ended December 31, 2020 and were included in other current assets in the consolidated balance sheet. Management believes that these payables or receivables are properly stated and are not likely to be settled for a significantly different amount. The net adjustments to estimated cost report settlements resulted in decreases to revenue of $5.4 million, $1.3 million and $0.4 million for the years ended December 31, 2021, 2020 and 2019, respectively.

The Company provides care without charge to patients who are financially unable to pay for the healthcare services they receive based on Company policies and federal and state poverty thresholds. Such amounts determined to qualify as charity care are not reported as revenue. The cost of providing charity care services were $3.8 million, $4.4 million and $4.3 million for the years ended December 31, 2021, 2020 and 2019, respectively. The estimated cost of charity care services was determined using a ratio of cost to gross charges determined from the Company’s most recently filed Medicare cost reports and applying that ratio to the gross charges associated with providing charity care for the period.

The following table presents revenue by payor type and as a percentage of revenue in the Company’s U.S. Facilities for the years ended December 31, 2021, 2020 and 2019 (in thousands):

 

 

 

Year Ended December 31,

 

 

 

2021

 

 

2020

 

 

2019

 

 

 

Amount

 

 

%

 

 

Amount

 

 

%

 

 

Amount

 

 

%

 

Commercial

 

$

684,292

 

 

 

29.6

%

 

$

596,698

 

 

 

28.5

%

 

$

565,350

 

 

 

28.2

%

Medicare

 

 

364,598

 

 

 

15.8

%

 

 

330,070

 

 

 

15.8

%

 

 

294,691

 

 

 

14.7

%

Medicaid

 

 

1,147,884

 

 

 

49.6

%

 

 

1,037,852

 

 

 

49.7

%

 

 

1,007,102

 

 

 

50.1

%

Self-Pay

 

 

93,425

 

 

 

4.0

%

 

 

98,302

 

 

 

4.7

%

 

 

118,716

 

 

 

5.9

%

Other

 

 

24,195

 

 

 

1.0

%

 

 

27,007

 

 

 

1.3

%

 

 

22,522

 

 

 

1.1

%

Revenue

 

$

2,314,394

 

 

 

100.0

%

 

$

2,089,929

 

 

 

100.0

%

 

$

2,008,381

 

 

 

100.0

%

 

Contract liabilities primarily consisted of unearned revenue from CMS’ Accelerated and Advance Payment Program. In April 2020, the Company received approximately $45 million from CMS’ Accelerated and Advance Payment Program for Medicare providers. The Company repaid approximately $25 million of the $45 million of advance payments during 2021 via recoupment from the Company’s new Medicare claims and will continue to repay the remaining balance throughout 2022. Contract liabilities of $30.4 million are included in other accrued liabilities at December 31, 2021 on the consolidated balance sheet. Contract liabilities of $35.9 million and $11.3 million are included in other accrued liabilities and other liabilities, respectively, at December 31, 2020 on the consolidated balance sheet. A summary of the activity in contract liabilities is as follows (in thousands):

 

Balance at December 31, 2020

 

$

47,196

 

Payments received

 

 

11,739

 

Revenue recognized

 

 

(3,463

)

Medicare advance repayments

 

 

(25,101

)

Balance at December 31, 2021

 

$

30,371