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General - Concentration of Business (Details) - USD ($)
$ in Thousands
3 Months Ended
Mar. 31, 2020
Mar. 31, 2019
Dec. 31, 2019
Significant customers      
Net revenue $ 1,794,307 $ 1,739,489  
Accounts receivable, net $ 923,716   $ 890,065
Minimum      
Significant customers      
Term of contracts with customers 1 year    
Term of contract extensions or renewals 1 year    
Notice period for termination of contract 30 days    
Maximum      
Significant customers      
Term of contracts with customers 3 years    
Term of contract extensions or renewals 2 years    
Notice period for termination of contract 180 days    
Pennsylvania Counties      
Significant customers      
Net revenue $ 137,000 131,700  
CMS      
Significant customers      
Net revenue 55,700 63,300  
Accounts receivable, net 115,200 117,400  
United States federal government      
Significant customers      
Net revenue $ 69,900 $ 79,500