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General - Concentration of Business (Details) - USD ($)
$ in Thousands
3 Months Ended 9 Months Ended
Sep. 30, 2017
Sep. 30, 2016
Sep. 30, 2017
Sep. 30, 2016
Concentration of Business        
Net revenue $ 1,419,406 $ 1,292,132 $ 4,144,168 $ 3,573,499
Minimum        
Concentration of Business        
Term of Contract     1 year  
Term of renewed contract     1 year  
Notice period for termination of contract     60 days  
Maximum        
Concentration of Business        
Term of Contract     3 years  
Term of renewed contract     2 years  
Notice period for termination of contract     180 days  
CMS        
Concentration of Business        
Net revenue     $ 368,200 192,000
Pennsylvania Counties        
Concentration of Business        
Net revenue     357,300 343,200
Agencies and departments of the United States federal government        
Concentration of Business        
Net revenue     $ 257,700 $ 164,300