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UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, DC 20549
 
Form 10-Q
 
Quarterly report pursuant to Section 13 or 15(d) of the Securities Exchange Act of 1934 for the quarterly period ended September 30, 2021
 
OR
Transition report pursuant to Section 13 or 15(d) of the Securities Exchange Act of 1934 for the transition period from               to
 
Commission File Number 1-7293
 
_________________________________________
TENET HEALTHCARE CORPORATION
(Exact name of Registrant as specified in its charter)
_________________________________________
Nevada95-2557091
(State of Incorporation)(IRS Employer Identification No.)
14201 Dallas Parkway
Dallas, TX 75254
(Address of principal executive offices, including zip code)
 
(469893-2200
(Registrant’s telephone number, including area code)
_________________________________________
Securities registered pursuant to Section 12(b) of the Act:
Title of each classTrading symbolName of each exchange on which registered
Common stock,$0.05 par valueTHCNew York Stock Exchange
6.875% Senior Notes due 2031THC31New York Stock Exchange

Indicate by check mark whether the Registrant (1) has filed all reports required to be filed by Section 13 or 15(d) of the Securities Exchange Act of 1934 during the preceding 12 months, and (2) has been subject to such filing requirements for the past 90 days.   Yes x No ¨
 
Indicate by check mark whether the Registrant has submitted electronically every Interactive Data File required to be submitted pursuant to Rule 405 of Regulation S-T during the preceding 12 months.   Yes x No ¨
 
Indicate by check mark whether the Registrant is a large accelerated filer, an accelerated filer, a non-accelerated filer, a smaller reporting company or an emerging growth company (each as defined in Exchange Act Rule 12b-2).
Large accelerated filer
x
Accelerated filer¨Non-accelerated filer¨
Smaller reporting company
Emerging growth company

If an emerging growth company, indicate by check mark if the Registrant has elected not to use the extended transition period for complying with any new or revised financial accounting standards provided pursuant to Section 13(a) of the Exchange Act. ¨

Indicate by check mark whether the Registrant is a shell company (as defined in Exchange Act Rule 12b-2).   Yes  No x

At October 22, 2021, there were 107,125,882 shares of the Registrant’s common stock outstanding.


TENET HEALTHCARE CORPORATION
TABLE OF CONTENTS
i

PART I. FINANCIAL INFORMATION
ITEM 1. FINANCIAL STATEMENTS
TENET HEALTHCARE CORPORATION AND SUBSIDIARIES
CONDENSED CONSOLIDATED BALANCE SHEETS
Dollars in Millions
(Unaudited)
September 30,December 31,
20212020
ASSETS
Current assets:
Cash and cash equivalents$2,292 $2,446 
Accounts receivable2,742 2,690 
Inventories of supplies, at cost376 368 
Assets held for sale 140 
Other current assets1,495 1,503 
Total current assets 6,905 7,147 
Investments and other assets2,564 2,534 
Deferred income taxes140 325 
Property and equipment, at cost, less accumulated depreciation and amortization
($5,872 at September 30, 2021 and $6,043 at December 31, 2020)
6,162 6,692 
Goodwill8,662 8,808 
Other intangible assets, at cost, less accumulated amortization
($1,326 at September 30, 2021 and $1,284 at December 31, 2020)
1,480 1,600 
Total assets $25,913 $27,106 
LIABILITIES AND EQUITY  
Current liabilities:  
Current portion of long-term debt$125 $145 
Accounts payable1,100 1,207 
Accrued compensation and benefits1,071 942 
Professional and general liability reserves268 243 
Accrued interest payable262 248 
Liabilities held for sale 70 
Contract liabilities1,218 659 
Other current liabilities1,335 1,333 
Total current liabilities 5,379 4,847 
Long-term debt, net of current portion14,009 15,574 
Professional and general liability reserves762 735 
Defined benefit plan obligations444 497 
Deferred income taxes29 29 
Contract liabilities – long-term15 918 
Other long-term liabilities1,592 1,617 
Total liabilities 22,230 24,217 
Commitments and contingencies
Redeemable noncontrolling interests in equity of consolidated subsidiaries2,048 1,952 
Equity:  
Shareholders’ equity:  
Common stock, $0.05 par value; authorized 262,500,000 shares; 155,402,362 shares
issued at September 30, 2021 and 154,407,524 shares issued at December 31, 2020
8 7 
Additional paid-in capital4,862 4,844 
Accumulated other comprehensive loss(274)(281)
Accumulated deficit(1,463)(2,128)
Common stock in treasury, at cost, 48,333,196 shares at September 30, 2021 and
48,337,947 shares at December 31, 2020
(2,411)(2,414)
Total shareholders’ equity722 28 
Noncontrolling interests 913 909 
Total equity 1,635 937 
Total liabilities and equity $25,913 $27,106 

See accompanying Notes to Condensed Consolidated Financial Statements.


TENET HEALTHCARE CORPORATION AND SUBSIDIARIES
CONDENSED CONSOLIDATED STATEMENTS OF OPERATIONS
Dollars in Millions, Except Per-Share Amounts
(Unaudited) 
Three Months Ended
September 30,
Nine Months Ended
September 30,
2021202020212020
Net operating revenues $4,894 $4,557 $14,629 $12,725 
Grant income3 (66)53 445 
Equity in earnings of unconsolidated affiliates45 44 141 103 
Operating expenses:  
Salaries, wages and benefits2,209 2,142 6,690 6,193 
Supplies827 784 2,490 2,158 
Other operating expenses, net1,051 1,058 3,177 3,054 
Depreciation and amortization209 215 654 624 
Impairment and restructuring charges, and acquisition-related costs15 57 55 166 
Litigation and investigation costs29 9 64 13 
Net gains on sales, consolidation and deconsolidation of facilities(412)(1)(427)(4)
Operating income1,014 271 2,120 1,069 
Interest expense(227)(263)(702)(761)
Other non-operating income, net7  16 3 
Loss from early extinguishment of debt(20)(312)(74)(316)
Income (loss) from continuing operations, before income taxes774 (304)1,360 (5)
Income tax benefit (expense)(197)197 (303)227 
Income (loss) from continuing operations, before discontinued operations577 (107)1,057 222 
Discontinued operations:  
Income from operations1 1   
Income from discontinued operations1 1   
Net income (loss)578 (106)1,057 222 
Less: Net income available to noncontrolling interests129 90 392 237 
Net income available (loss attributable) to Tenet Healthcare Corporation common shareholders$449 $(196)$665 $(15)
Amounts available (attributable) to Tenet Healthcare Corporation common shareholders  
Income (loss) from continuing operations, net of tax$448 $(197)$665 $(15)
Income from discontinued operations, net of tax1 1   
Net income available (loss attributable) to Tenet Healthcare Corporation common shareholders$449 $(196)$665 $(15)
Earnings (loss) per share available (attributable) to Tenet Healthcare Corporation common shareholders:  
Basic  
Continuing operations$4.18 $(1.87)$6.23 $(0.14)
Discontinued operations0.01 0.01   
 $4.19 $(1.86)$6.23 $(0.14)
Diluted  
Continuing operations$4.12 $(1.87)$6.13 $(0.14)
Discontinued operations0.01 0.01   
 $4.13 $(1.86)$6.13 $(0.14)
Weighted average shares and dilutive securities outstanding (in thousands):  
Basic107,050 105,263 106,727 104,803 
Diluted108,761 105,263 108,465 104,803 

See accompanying Notes to Condensed Consolidated Financial Statements.

2

TENET HEALTHCARE CORPORATION AND SUBSIDIARIES
CONDENSED CONSOLIDATED STATEMENTS OF OTHER COMPREHENSIVE INCOME
Dollars in Millions
(Unaudited)
 
Three Months Ended
September 30,
Nine Months Ended
September 30,
2021202020212020
Net income (loss)$578 $(106)$1,057 $222 
Other comprehensive income:
Amortization of net actuarial loss included in other non-operating income, net2 2 8 6 
Unrealized gains on debt securities held as available-for-sale   1 
Foreign currency translation adjustments1  1  
Other comprehensive income before income taxes3 2 9 7 
Income tax benefit (expense) related to items of other comprehensive income 2 (2)(1)
Total other comprehensive income, net of tax3 4 7 6 
Comprehensive net income (loss)581 (102)1,064 228 
Less: Comprehensive income available to noncontrolling interests129 90 392 237 
Comprehensive income available (loss attributable) to Tenet Healthcare Corporation common shareholders$452 $(192)$672 $(9)

See accompanying Notes to Condensed Consolidated Financial Statements.

3

TENET HEALTHCARE CORPORATION AND SUBSIDIARIES
CONDENSED CONSOLIDATED STATEMENTS OF CASH FLOWS
Dollars in Millions
(Unaudited)
Nine Months Ended
September 30,
20212020
Net income$1,057 $222 
Adjustments to reconcile net income to net cash provided by operating activities:
Depreciation and amortization654 624 
Deferred income tax expense (benefit)183 (246)
Stock-based compensation expense43 38 
Impairment and restructuring charges, and acquisition-related costs55 166 
Litigation and investigation costs64 13 
Net gains on sales, consolidation and deconsolidation of facilities(427)(4)
Loss from early extinguishment of debt74 316 
Equity in earnings of unconsolidated affiliates, net of distributions received10 (11)
Amortization of debt discount and debt issuance costs25 30 
Other items, net(23)(4)
Changes in cash from operating assets and liabilities:  
Accounts receivable(202)280 
Inventories and other current assets(111)30 
Income taxes67 9 
Accounts payable, accrued expenses, contract liabilities and other current liabilities(149)1,546 
Other long-term liabilities8 205 
Payments for restructuring charges, acquisition-related costs, and litigation costs and
settlements
(116)(252)
Net cash used in operating activities from discontinued operations, excluding income taxes(1)(1)
Net cash provided by operating activities1,211 2,961 
Cash flows from investing activities:  
Purchases of property and equipment(354)(374)
Purchases of businesses or joint venture interests, net of cash acquired(64)(61)
Proceeds from sales of facilities and other assets1,235 13 
Proceeds from sales of marketable securities, long-term investments and other assets18 44 
Purchases of marketable securities and equity investments(23)(41)
Other items, net(10)13 
Net cash provided by (used in) investing activities802 (406)
Cash flows from financing activities:  
Repayments of borrowings under credit facility (740)
Proceeds from borrowings under credit facility 740 
Repayments of other borrowings(3,183)(3,244)
Proceeds from other borrowings1,413 3,815 
Debt issuance costs(15)(48)
Distributions paid to noncontrolling interests(316)(184)
Proceeds from sale of noncontrolling interests14 7 
Purchases of noncontrolling interests(19)(34)
Proceeds from shares issued under stock-based compensation plans, net of taxes paid related
to net share settlement
11 13 
Medicare advances and grants received by unconsolidated affiliates, net of recoupment(8)150 
Other items, net(64)8 
Net cash provided by (used in) financing activities(2,167)483 
Net increase (decrease) in cash and cash equivalents(154)3,038 
Cash and cash equivalents at beginning of period2,446 262 
Cash and cash equivalents at end of period$2,292 $3,300 
Supplemental disclosures:  
Interest paid, net of capitalized interest$(664)$(757)
Income tax payments, net$(54)$(10)
 
See accompanying Notes to Condensed Consolidated Financial Statements.

4

TENET HEALTHCARE CORPORATION
NOTES TO CONDENSED CONSOLIDATED FINANCIAL STATEMENTS

NOTE 1. BASIS OF PRESENTATION 
Description of Business and Basis of Presentation
Tenet Healthcare Corporation (together with our subsidiaries, referred to herein as “Tenet,” “we,” “our” or “us”) is a diversified healthcare services company headquartered in Dallas, Texas. Through an expansive care network that includes USPI Holding Company, Inc. (“USPI”), at September 30, 2021 we operated 60 hospitals and approximately 460 other healthcare facilities, including surgical hospitals, ambulatory surgery centers, imaging centers, and other care sites and clinics. We also operate Conifer Health Solutions, LLC through our Conifer Holdings, Inc. (“Conifer”) subsidiary, which provides revenue cycle management and value‑based care services to hospitals, health systems, physician practices, employers and other clients.

This quarterly report supplements our Annual Report on Form 10‑K for the year ended December 31, 2020 (“Annual Report”). As permitted by the Securities and Exchange Commission for interim reporting, we have omitted certain notes and disclosures that substantially duplicate those in our Annual Report. For further information, refer to the audited Consolidated Financial Statements and notes included in our Annual Report. Unless otherwise indicated, all financial and statistical data included in these notes to our Condensed Consolidated Financial Statements relate to our continuing operations, with dollar amounts expressed in millions (except per‑share amounts).

Although the Condensed Consolidated Financial Statements and related notes within this document are unaudited, we believe all adjustments considered necessary for a fair presentation have been included and are of a normal recurring nature. In preparing our financial statements in conformity with accounting principles generally accepted in the United States (“GAAP”), we are required to make estimates and assumptions that affect the amounts reported in our Condensed Consolidated Financial Statements and these accompanying notes. We regularly evaluate the accounting policies and estimates we use. In general, we base the estimates on historical experience and on assumptions that we believe to be reasonable given the particular circumstances in which we operate. Actual results may vary from those estimates. Financial and statistical information we report to other regulatory agencies may be prepared on a basis other than GAAP or using different assumptions or reporting periods and, therefore, may vary from amounts presented herein. Although we make every effort to ensure that the information we report to those agencies is accurate, complete and consistent with applicable reporting guidelines, we cannot be responsible for the accuracy of the information they make available to the public.

Operating results for the three and nine‑month periods ended September 30, 2021 are not necessarily indicative of the results that may be expected for the full year. Reasons for this include, but are not limited to: the impact of the COVID‑19 pandemic on our operations, business, financial condition and cash flows; the impact of the demand for, and availability of, qualified medical personnel on compensation costs; overall revenue and cost trends, particularly the timing and magnitude of price changes; fluctuations in contractual allowances and cost report settlements and valuation allowances; managed care contract negotiations, settlements or terminations and payer consolidations; trends in patient accounts receivable collectability and associated implicit price concessions; fluctuations in interest rates; levels of malpractice insurance expense and settlement trends; impairment of long‑lived assets and goodwill; restructuring charges; losses, costs and insurance recoveries related to natural disasters and other weather‑related occurrences; litigation and investigation costs; acquisitions and dispositions of facilities and other assets; gains (losses) on sales, consolidation and deconsolidation of facilities; income tax rates and deferred tax asset valuation allowance activity; changes in estimates of accruals for annual incentive compensation; the timing and amounts of stock option and restricted stock unit grants to employees and directors; gains (losses) from early extinguishment of debt; and changes in occupancy levels and patient volumes. Factors that affect service mix, revenue mix, patient volumes and, thereby, the results of operations at our hospitals and related healthcare facilities include, but are not limited to: changes in federal, state and local healthcare and business regulations, including mandated closures and other operating restrictions; the business environment, economic conditions and demographics of local communities in which we operate; the number of uninsured and underinsured individuals in local communities treated at our hospitals; disease hotspots and seasonal cycles of illness; climate and weather conditions; physician recruitment, satisfaction, retention and attrition; advances in technology and treatments that reduce length of stay; local healthcare competitors; utilization pressure by managed care organizations, as well as managed care contract negotiations or terminations; hospital performance data on quality measures and patient satisfaction, as well as standard charges for services; any unfavorable publicity about us, or our joint venture partners, that impacts our relationships with physicians and patients; and changing consumer behavior, including with respect to the timing of elective procedures. These considerations apply to year‑to‑year comparisons as well.

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Certain prior‑year amounts have been reclassified to conform to the current year presentation. In the accompanying Condensed Consolidated Balance Sheets, income tax receivable has been reclassified to other current assets, as it is no longer significant enough to present separately. In the accompanying Condensed Consolidated Statements of Cash Flows, long‑term assets has been combined with other items, net, as it is no longer significant enough to present separately, but it remains located within cash flows from investing activities.

COVID19 Pandemic
During 2020, federal, state and local authorities undertook several actions designed to assist healthcare providers in providing care to COVID‑19 and other patients and to mitigate the adverse economic impact of the COVID‑19 pandemic. Legislative actions taken by the federal government during 2020 included the Coronavirus Aid, Relief, and Economic Security Act, the Paycheck Protection Program and Health Care Enhancement Act, the Continuing Appropriations Act, 2021 and Other Extensions Act, and the Consolidated Appropriations Act, 2021 (collectively, the “COVID Acts”). With the COVID Acts, the federal government authorized funding to be distributed through the Public Health and Social Services Emergency Fund (“Provider Relief Fund” or “PRF”). In June 2021, the U.S. Department of Health and Human Services (“HHS”) established new deadlines for when recipients of PRF grants must use the funding received, generally 12 to 18 months after receipt of the grant funds. HHS will recoup PRF grant funds not utilized by the established deadlines. The COVID Acts also revised the Medicare accelerated payment program in an attempt to disburse payments to hospitals and other care providers more quickly and permitted employers to defer payment of the 6.2% employer Social Security tax beginning March 27, 2020 through December 31, 2020. Our participation in these programs and the related accounting policies are summarized below.

Grant Income. During the three and nine months ended September 30, 2021, we received cash payments of $2 million and $65 million, respectively, from the Provider Relief Fund and state and local grant programs, including $27 million received by our unconsolidated affiliates during the nine‑month period. During the three and nine months ended September 30, 2020, we received cash payments of $178 million and $890 million, respectively, from the Provider Relief Fund and state and local grant programs, including $4 million and $42 million received by our unconsolidated affiliates during the three and nine‑month periods, respectively. We recognize grant payments as income when there is reasonable assurance that we have complied with the conditions associated with the grant. Our estimates could change materially in the future based on our operating performance or COVID‑19 activities, as well as the government’s grant compliance guidance. Grant income recognized by our Hospital Operations and other (“Hospital Operations”) and Ambulatory Care segments is presented in grant income, and grant income recognized through our unconsolidated affiliates is presented in equity in earnings of unconsolidated affiliates in our statement of operations. During the three and nine months ended September 30, 2021, we recognized grant income of $2 million and $30 million, respectively, in our Hospital Operations segment, and $1 million and $23 million, respectively, in our Ambulatory Care segment. We recognized an additional $1 million and $12 million of Provider Relief Fund income during these periods, which was classified as equity in earnings of unconsolidated affiliates in the accompanying Condensed Consolidated Statements of Operations for the three and nine months ended September 30, 2021, respectively. During the three and nine months ended September 30, 2020, we recognized net grant income of $(57) million and $417 million, respectively, in our Hospital Operations segment, and $(9) million and $28 million, respectively, in our Ambulatory Care segment. Additionally, we recognized $(4) million and $8 million, respectively, of net grant income as equity in earnings of unconsolidated affiliates during the three and nine months ended September 30, 2020. We recognized a reduction of grant income in the three months ended September 30, 2020 to comply with revised grant guidelines HHS published in September 2020. At September 30, 2021 and December 31, 2020, we had deferred grant payments remaining of $3 million and $18 million, respectively, which amounts were recorded in other current liabilities in the accompanying Condensed Consolidated Balance Sheets for those periods.

Medicare Accelerated Payment Program. In certain circumstances, when a hospital is experiencing financial difficulty due to delays in receiving payment for the Medicare services it provided, it may be eligible for an accelerated or advance payment pursuant to the Medicare accelerated payment program. The COVID Acts revised the Medicare accelerated payment program in an attempt to disburse payments to healthcare providers more quickly. Recipients may retain the accelerated payments for one year from the date of receipt before recoupment commences, which is effectuated by a 25% offset of claims payments for 11 months, followed by a 50% offset for the succeeding six months. At the end of the 29‑month period, interest on the unpaid balance will be assessed at 4.00% per annum. The initial 11‑month recoupment period began in April 2021.

Our Hospital Operations and Ambulatory Care segments both received advance payments from the Medicare accelerated payment program during 2020. No additional advances were received in the nine months ended September 30, 2021. During the three and nine months ended September 30, 2021, $161 million and $302 million, respectively, of advances received by our Hospital Operations segment and $13 million and $24 million, respectively, of advances received by our Ambulatory Care segment were recouped through a reduction of our Medicare claims payments. In addition, $14 million and $26 million of advances received by unconsolidated affiliates for which we provide cash management services were
6

recouped through a reduction of those affiliates’ Medicare claims payments during the same three and nine-month periods, respectively. In the accompanying Condensed Consolidated Balance Sheets, advances totaling $1.144 billion and $603 million were included in contract liabilities at September 30, 2021 and December 31, 2020, respectively, and advances totaling $902 million were included in contract liabilities – long term at December 31, 2020.

Deferral of Employer Payroll Tax Match Payments. Social Security taxes deferred under the COVID Acts are required to be paid in equal amounts over two years, with payments due in December 2021 and December 2022. We had deferred Social Security tax payments totaling $130 million included in accrued compensation and benefits and $130 million included in other long‑term liabilities in the accompanying Condensed Consolidated Balance Sheets at both September 30, 2021 and December 31, 2020.

Cash and Cash Equivalents
We treat highly liquid investments with original maturities of three months or less as cash equivalents. Cash and cash equivalents were $2.292 billion and $2.446 billion at September 30, 2021 and December 31, 2020, respectively. At September 30, 2021 and December 31, 2020, our book overdrafts were $155 million and $154 million, respectively, which were classified as accounts payable.

At September 30, 2021 and December 31, 2020, $169 million and $166 million, respectively, of total cash and cash equivalents in the accompanying Condensed Consolidated Balance Sheets were intended for the operations of our captive insurance subsidiaries.

Also at September 30, 2021 and December 31, 2020, we had $51 million and $93 million, respectively, of property and equipment purchases accrued for items received but not yet paid. Of these amounts, $45 million and $85 million, respectively, were included in accounts payable.

During the nine months ended September 30, 2021 and 2020, we recorded right‑of‑use assets related to non‑cancellable finance leases of $81 million and $75 million, respectively, and related to non‑cancellable operating leases of $121 million and $135 million, respectively.

Other Intangible Assets
The following tables provide information regarding other intangible assets, which were included in the accompanying Condensed Consolidated Balance Sheets at September 30, 2021 and December 31, 2020: 
Gross Carrying
Amount
Accumulated
Amortization
Net Book Value
At September 30, 2021:
Capitalized software costs$1,732 $(1,123)$609 
Trade names102  102 
Contracts870 (124)746 
Other102 (79)23 
Total$2,806 $(1,326)$1,480 
Gross Carrying
Amount
Accumulated
Amortization
Net Book Value
At December 31, 2020:
Capitalized software costs$1,800 $(1,084)$716 
Trade names102  102 
Contracts872 (111)761 
Other110 (89)21 
Total$2,884 $(1,284)$1,600 

Estimated future amortization of intangibles with finite useful lives at September 30, 2021 is as follows: 
  Three Months EndingYears EndingLater Years
December 31,
 Total20212022202320242025
Amortization of intangible assets$796 $53 $124 $110 $98 $83 $328 
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We recognized amortization expense of $139 million and $127 million in the accompanying Condensed Consolidated Statements of Operations for the nine months ended September 30, 2021 and 2020, respectively.

Investments in Unconsolidated Affiliates
We control 232 of the facilities within our Ambulatory Care segment and, therefore, consolidate their results. We account for many of the facilities our Ambulatory Care segment operates (110 of 342 at September 30, 2021), as well as additional companies in which our Hospital Operations segment holds ownership interests, under the equity method as investments in unconsolidated affiliates and report only our share of net income as equity in earnings of unconsolidated affiliates in the accompanying Condensed Consolidated Statements of Operations. Equity in earnings of unconsolidated affiliates included $1 million and $12 million for the three and nine months ended September 30, 2021, respectively, from PRF grants recognized by our Ambulatory Care segment’s unconsolidated affiliates. During the three and nine months ended September 30, 2020, equity in earnings of unconsolidated affiliates included $(4) million and $8 million, respectively, from PRF grants recognized by these unconsolidated affiliates. During the three months ended September 30, 2020, we recognized a reduction of grant income reported in previous periods to comply with revised grant guidelines HHS published in September 2020. Summarized financial information for these equity method investees is included in the following table. For investments acquired during the reported periods, amounts reflect 100% of the investee’s results beginning on the date of our acquisition of the investment.
 Three Months Ended
September 30,
Nine Months Ended
September 30,
 2021202020212020
Net operating revenues$720 $697 $2,065 $1,731 
Net income$178 $167 $540 $414 
Net income available to the investees$108 $101 $325 $253 

NOTE 2. ACCOUNTS RECEIVABLE
The principal components of accounts receivable are shown in the table below: 
 September 30, 2021December 31, 2020
Continuing operations:  
Patient accounts receivable$2,558 $2,499 
Estimated future recoveries139 156 
Net cost reports and settlements receivable and valuation allowances44 34 
 2,741 2,689 
Discontinued operations1 1 
Accounts receivable, net $2,742 $2,690 

The following table summarizes the amount and classification of assets and liabilities in the accompanying Condensed Consolidated Balance Sheets related to California’s provider fee program at September 30, 2021 and December 31, 2020:
 September 30, 2021December 31, 2020
Assets:
Other current assets$257 $378 
Investments and other assets$318 $206 
Liabilities:
Other current liabilities$93 $110 
Other long-term liabilities$98 $56 

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The following table shows our estimated costs (based on selected operating expenses, which include salaries, wages and benefits, supplies and other operating expenses) of caring for our uninsured and charity patients in the three and nine months ended September 30, 2021 and 2020:
 Three Months Ended
September 30,
Nine Months Ended
September 30,
 2021202020212020
Estimated costs for:    
Uninsured patients$181 $165 $507 $466 
Charity care patients25 30 74 113 
Total
$206 $195 $581 $579 
 
NOTE 3. CONTRACT BALANCES
Hospital Operations Segment
Amounts related to services provided to patients for which we have not billed and that do not meet the conditions of unconditional right to payment at the end of the reporting period are contract assets. For our Hospital Operations segment, our contract assets include services that we have provided to patients who are still receiving inpatient care in our facilities at the end of the reporting period. Our Hospital Operations segment’s contract assets were included in other current assets in the accompanying Condensed Consolidated Balance Sheets at September 30, 2021 and December 31, 2020. Approximately 91% of our Hospital Operations segment’s contract assets meet the conditions for unconditional right to payment and are reclassified to patient receivables within 90 days.

In certain circumstances, when a hospital is experiencing financial difficulty due to delays in receiving payment for the Medicare services it provided, it may be eligible for an accelerated or advance payment pursuant to the Medicare accelerated payment program. As discussed in Note 1, the COVID Acts revised the Medicare accelerated payment program in an attempt to disburse payments to hospitals more quickly. During the year ended December 31, 2020, our Hospital Operations segment received advance payments from the Medicare accelerated payment program following its expansion under the COVID Acts. These advance payments were recorded as contract liabilities in the accompanying Condensed Consolidated Balance Sheets at September 30, 2021 and December 31, 2020. No additional advances were received in the three and nine months ended September 30, 2021.

The opening and closing balances of contract assets and contract liabilities for our Hospital Operations segment are as follows:
Contract Liability –Contract Liability –
CurrentLong-term
Contract AssetsAdvances from MedicareAdvances from Medicare
December 31, 2020$208 $510 $819 
September 30, 2021190 1,031  
Increase (decrease)$(18)$521 $(819)

December 31, 2019$170 $ $ 
September 30, 2020171 1,270  
Increase$1 $1,270 $ 

During the three and nine months ended September 30, 2021, $161 million and $302 million, respectively, of Medicare advance payments included in the opening contract liabilities balance for our Hospital Operations segment were recouped through a reduction of our Medicare claims payments.

Ambulatory Care Segment
During the year ended December 31, 2020, our Ambulatory Care segment also received advance payments from the expanded Medicare accelerated payment program. At September 30, 2021, contract liabilities in the accompanying Condensed Consolidated Balance Sheet included $78 million of Medicare advance payments received by our unconsolidated affiliates for whom we provide cash management services. At December 31, 2020, contract liabilities and contract liabilities – long‑term in the accompanying Condensed Consolidated Balance Sheet included $51 million and $62 million, respectively, of Medicare advance payments received by our unconsolidated affiliates for whom we provide cash management services.

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The opening and closing balances of contract liabilities for our Ambulatory Care segment are as follows:
Contract Liability –Contract Liability –
CurrentLong-term
Advances from MedicareAdvances from Medicare
December 31, 2020$93 $83 
September 30, 2021113  
Increase (decrease)$20 $(83)
December 31, 2019$ $ 
September 30, 2020172  
Increase$172 $ 

During the three and nine months ended September 30, 2021, $13 million and $24 million, respectively, of Medicare advance payments included in the opening contract liabilities balance for our Ambulatory Care segment were recouped through a reduction of our Medicare claims payments. Additionally, $14 million and $26 million of Medicare advances received by our unconsolidated affiliates for whom we provide cash management services included in the opening contract liabilities balance were recouped during the three and nine months ended September 30, 2021, respectively.

Conifer Segment
Conifer enters into contracts with customers to provide revenue cycle management and other services, such as value‑based care, consulting and project services. The payment terms and conditions in our customer contracts vary. In some cases, customers are invoiced in advance and (for other than fixed‑price fee arrangements) a true‑up to the actual fee is included on a subsequent invoice. In other cases, payment is due in arrears. In addition, some contracts contain performance incentives, penalties and other forms of variable consideration. When the timing of Conifer’s delivery of services is different from the timing of payments made by the customers, Conifer recognizes either unbilled revenue (performance precedes contractual right to invoice the customer) or deferred revenue (customer payment precedes Conifer service performance). In the following table, customers that prepay prior to obtaining control/benefit of the service are represented by deferred contract revenue until the performance obligations are satisfied. Unbilled revenue represents arrangements in which Conifer has provided services to and the customer has obtained control/benefit of services prior to the contractual invoice date. Contracts with payment in arrears are recognized as receivables in the month the service is performed.

The opening and closing balances of Conifer’s receivables, contract assets and contract liabilities are as follows:
Contract Liability –Contract Liability –
Contract Asset –CurrentLong-Term
ReceivablesUnbilled RevenueDeferred RevenueDeferred Revenue
December 31, 2020$56 $20 $