Revenue Recognition and Accounts Receivable

6 Months Ended

Jun. 30, 2020

Revenue from Contract with Customer [Abstract]

Revenue Recognition and Accounts Receivable

(2)         Revenue Recognition and Accounts Receivable

Revenue Recognition

The Company generates revenues for services and related products that the Company provides to patients for home medical equipment, related supplies, and other items. The Company’s revenues are recognized in the period in which services and related products are provided to customers and are recorded either at a point in time for the sale of supplies and disposables, or over the fixed monthly service period for equipment.

Revenues are recognized when control of the promised good or service is transferred to customers, in an amount that reflects the consideration to which the Company expects to receive from patients or under reimbursement arrangements with Medicare, Medicaid and third-party payors, in exchange for those goods and services.

Sales revenue is recognized upon transfer of control of products or services to customers in an amount that reflects the consideration the Company expects to receive in exchange for those products or services. Revenues for the sale of durable medical equipment and related supplies, including oxygen equipment, ventilators, wheelchairs, hospital beds and infusion pumps, are recognized at the time of delivery.

The Company provides certain equipment to patients which is reimbursed periodically in fixed monthly payments for as long as the patient is using the equipment and medical necessity continues (in certain cases, the fixed monthly payments are capped at a certain amount). The equipment provided to the patient is based upon medical necessity as documented by prescriptions and other documentation received from the patient’s physician. The patient generally does not negotiate or have input with respect to the manufacturer or model of the equipment prescribed by their physician and delivered by the Company. Once initial delivery of this equipment is made to the patient for initial setup, a monthly billing process is established based on the initial setup service date. The Company recognizes the fixed monthly revenue ratably over the service period as earned, less estimated adjustments, and defers revenue for the portion of the monthly bill that is unearned. No separate revenue is earned from the initial setup process. Included in fixed monthly revenue are unbilled amounts for which the revenue recognition criteria had been met as of period-end but were not yet billed to the payor. The estimate of net unbilled fixed monthly revenue recognized is based on historical trends and estimates of future collectability.

The Company disaggregates net revenue from contracts with customers by payor type and by core service lines. The Company believes that disaggregation of net revenue into these categories depicts how the nature, amount, timing and uncertainty of revenue and cash flows are affected by economic factors. The payment terms and conditions within the Company’s revenue-generating contracts vary by payor type and payor source.

The composition of net revenue by payor type for the three and six months ended June 30, 2020 and 2019 are as follows (in thousands):

	Three Months Ended June 30,				Six Months Ended June 30,
	2020			2019	2020		2019
Insurance	$	148,165	$	68,909	$	262,616	$	136,626
Government		60,513		40,578		111,758		78,679
Patient pay		23,438		14,667		49,181		28,347
Net revenue	$	232,116	$	124,154	$	423,555	$	243,652

The composition of net revenue by core service lines for the three and six months ended June 30, 2020 and 2019 are as follows (in thousands):

	Three Months Ended June 30,				Six Months Ended June 30,
	2020			2019	2020		2019
Net sales revenue:
Sleep	$	84,421	$	50,433	$	153,315	$	97,560
Supplies to the home		34,240		1,915		67,579		3,944
HME		12,727		10,236		24,306		20,725
Respiratory		18,114		1,445		20,882		2,724
Other		11,463		8,967		23,856		16,999
Total net sales revenue	$	160,965	$	72,996	$	289,938	$	141,952
Net revenue from fixed monthly equipment reimbursements:
Sleep	$	22,644	$	18,944	$	45,313	$	37,001
HME		13,262		10,202		25,439		20,445
Respiratory		30,856		20,009		55,863		40,438
Other		4,389		2,003		7,002		3,816
Total net revenue from fixed monthly equipment reimbursements	$	71,151	$	51,158	$	133,617	$	101,700
Total net revenue:
Sleep	$	107,065	$	69,377	$	198,628	$	134,561
Supplies to the home		34,240		1,915		67,579		3,944
HME		25,989		20,438		49,745		41,170
Respiratory		48,970		21,454		76,745		43,162
Other		15,852		10,970		30,858		20,815
Total net revenue	$	232,116	$	124,154	$	423,555	$	243,652

In response to the COVID-19 pandemic and the National Emergency Declaration, dated March 13, 2020, the Company increased its cash liquidity by, among other things, seeking recoupable advance payments of approximately $45.8 million made available by the Centers for Medicare & Medicaid Services(CMS) under the Coronavirus Aid, Relief, and Economic Security Act (the CARES Act) legislation, which was received in April 2020. The recoupment of such amount by CMS is expected to begin in the third quarter of 2020 and will be applied to services provided and revenue recognized during the period in which the recoupment occurs. In addition, in April 2020, the Company received distributions of the CARES Act provider relief funds of approximately $17.2 million targeted to offset lost revenue and expenditures incurred in connection with the COVID-19 pandemic. The provider relief funds are subject to certain restrictions and are subject to recoupment if not used for designated purposes. The Company is currently in the process of determining how much of the CARES Act provider relief funds it will be entitled to based on the terms and conditions of the program. The total of the recoupable advance payments and the CARES Act provider relief funds of approximately $63 million is included in other current liabilities in the consolidated balance sheets as of June 30, 2020.

Accounts Receivable

Due to the continuing changes in the healthcare industry and third-party reimbursement environment, certain estimates are required to record accounts receivable at their net realizable values. Inherent in these estimates is the risk that they will have to be revised or updated as additional information becomes available. The complexity of third-party billing arrangements and laws and regulations governing Medicare and Medicaid may result in adjustments to amounts originally recorded.

The Company performs a periodic analysis to review the valuation of accounts receivable and collectability of outstanding balances. Management’s evaluation takes into consideration such factors as historical bad debt experience, business and economic conditions, trends in healthcare coverage, other collection indicators and information about specific receivables. The Company’s evaluation also considers the age and composition of the outstanding amounts in determining their estimated net realizable value.

Included in accounts receivable are earned but unbilled accounts receivables. Billing delays, ranging from several days to several weeks, can occur due to the Company’s policy of compiling required payor specific documentation prior to billing for its services rendered. The Company recorded unbilled revenue of $16.8 million and $8.6 million as of June 30, 2020 and December 31, 2019, respectively.