What changed in this filing

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Item 1. Business

2021-03-01 compared with 2020-02-28 · 96 added, 78 removed, 277 unchanged (39% of the section changed)

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Physical Therapy, Inc.

(we, us, our or the Company), through its subsidiaries, operates outpatient physical therapy clinics that provide pre-and post-operative care for a variety of orthopedic-related disorders and sports-related injuries, treatment for neurological-related injuries and rehabilitation of injured workers.

and subsidiaries (“we”, “us”, “our” or the “Company”), operates its business through two reportable business segments.

Our reportable segments include the physical therapy operations segment and the industrial injury prevention services segment.

Our Company, through its subsidiaries, operates outpatient physical therapy clinics that provide pre-and post-operative care for a variety of orthopedic-related disorders and sports-related injuries, treatment for neurological-related injuries and rehabilitation of injured workers.

We primarily operate through subsidiary clinic partnerships in which we generally own a 1% general partnership interest and a 10% to 99% limited partnership interest and the managing therapist(s) of the clinics owns the remaining limited partnership interest in the majority of the clinics (hereinafter referred to as “Clinic Partnerships”).

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These services are performed through Industrial Sports Medicine Professionals, consisting of both physical therapists and specialized certified athletic trainers (ATCs).

Unless the context otherwise requires, references in this Annual Report on Form 10-K to we, our or us includes the Company and all of its subsidiaries.

Our strategy is to acquire single and multi-clinic outpatient physical therapy practices and to develop outpatient physical therapy clinics, primarily to operate as satellites in an existing partnership, on national basis.

Our strategy is to acquire multi-clinic outpatient physical therapy practices, to develop outpatient physical therapy clinics as satellites in existing partnerships, and to continue to acquire companies that provide industrial injury prevention services.

At December 31, 2020, we operated 554 clinics in 39 states.

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Our highest concentration of clinics are in the following states:

Texas, Tennessee, Michigan, Virginia, Florida, Oregon, Maryland, Georgia, Pennsylvania and Arizona.

Texas, Tennessee, Michigan, Virginia, Florida, Oregon, Maryland, Georgia, Pennsylvania, Arizona, Idaho and Missouri.

In addition to our 554 clinics, at December 31, 2020, we also managed 38 physical therapy practices for unrelated physician groups and hospitals, and operated the industrial injury prevention business, as described below.

During the last three years, we completed the following multi-clinic acquisitions:

During the last three years, we completed the following acquisitions:

November 2020 Acquisition

November 30, 2020

September 2020 Acquisition

September 30, 2020

February 2020 Acquisition

February 27, 2020

September 2019 Acquisition

September 30, 2019

August 2018 Acquisition

January 2017 Acquisition

May 2017 Acquisition

June 2017 Acquisition

October 2017 Acquisition

In addition to the above multi-clinic acquisitions, in March 2017, we acquired a 55% interest in the initial industrial injury prevention business.

August 31, 2018

The business includes six management and services contracts which had a remaining term of approximately five years as of the date acquired.

The four clinics are in four separate partnerships.

The Company's interest in the four partnerships range from 10.0% to 83.8%, with an overall 65.0% based on the initial purchase transaction.

In addition to the above acquisitions, in March 2017, we acquired a 55% interest in the initial industrial injury prevention business.

On April 30, 2018, we acquired a 65% interest in another business in the industrial injury prevention sector and in connection with the closing we combined the two businesses.

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On April 11, 2019, we acquired a third company that is a provider of industrial injury prevention services.

The acquired company specializes in delivering injury prevention and care, post offer employment testing, functional capacity evaluations and return-to-work services.

This acquired company specializes in delivering injury prevention and care, post offer employment testing, functional capacity evaluations and return-to-work services.

It performs these services across a network in 45 states including onsite at eleven client locations.

The business was then combined with Briotix Health increasing our ownership position in the partnership to approximately 76.0%.

After the acquisition, the business was then combined with Briotix Health increasing our ownership position in Briotix to approximately 76.0%.

During the year ended December 31, 2020, we sold 14 previously closed clinics.

The aggregate sales price was $1.1 million, of which $0.7 million was paid in cash and $0.4 million in a note receivable, payable in two equal installments of principal and any accrued interest on June 15, 2021 and 2022.

Also during 2019, we purchased the assets and business of one physical therapy clinic in a separate transaction.

The clinic operates as a satellite clinic of one of the existing partnerships.

Besides the August 2018 multi-clinic acquisition, through several of our majority owned Clinic Partnerships we acquired five separate clinic practices that year.

The clinic operates as a satellite clinic of one of our existing partnerships.

Besides the August 2018 multi-clinic acquisition referenced in the table above, we acquired five separate clinic practices that year through several of our majority owned Clinic Partnerships.

These practices operate as satellites of the respective existing Clinic Partnerships.

During 2017, we purchased the assets and business of two physical therapy clinics in separate transactions.

One clinic was consolidated with an existing clinic and the other operates as a satellite clinic of one of the existing partnerships.

The results of operations of the acquired clinics have been included in our consolidated financial statements since the date of their respective acquisition.

We continue to seek to attract for employment physical therapists who have established relationships with physicians and other referral sources by offering these therapists a competitive salary and incentives based on the profitability of the clinic that they manage.

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In addition, we have developed satellite clinic facilities as part of existing Clinic Partnerships and Wholly-Owned Facilities, with the result that a substantial number of Clinic Partnerships and Wholly-Owned Facilities operate more than one clinic location.

In 2020, we intend to continue to acquire clinic practices and continue to focus on developing new clinics and on opening satellite clinics where appropriate along with increasing our patient volume through marketing and new programs.

During 2021, we intend to continue to acquire multi-clinic practices and to continue to develop outpatient physical therapy clinics as satellites in existing partnerships, along with increasing our patient volume through marketing and new programs.

Therapists at our clinics initially perform a comprehensive evaluation of each patient, which is then followed by a treatment plan specific to the injury as prescribed by the patient’s physician.

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For the vast majority of the Clinic Partnerships, the managing healthcare practitioner is a physical therapist who owns the remaining limited partnership interest in the Clinic Partnership.

For our Clinic Partnership agreements related to those that we acquired a majority interest, generally, the prior management continues to own a 10% to 50% interest.

For our Clinic Partnership agreements related to those in which we acquired a majority interest, generally, the prior management continues to own a 10% to 50% interest.

Typically, each therapist partner or director, including those employed by Clinic Partnerships in which we acquired a majority interest, enters into an employment agreement for a term of up to five years with their Clinic Partnership.

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In the case of Clinic Partnerships, the therapist partner receives earnings distributions based upon their ownership interest.

Upon termination of employment, we typically have the right, but not the

obligation, to purchase the therapists partnership interest in de novo Clinic Partnerships.

Upon termination of employment, we typically have the right, but not the obligation, to purchase the therapist’s partnership interest in de novo Clinic Partnerships.

In connection with most of our acquired clinics, in the event that a limited minority partner’s employment ceases and certain requirements are met as detailed in the respective limited partnership agreements, we have a call right (the “Call Right”) and the selling entity or individual has a put right (the “Put Right”) with respect to the partner’s limited partnership interests.

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Under a management agreement, one of our subsidiaries provides a variety of support services to each clinic, including supervision of site selection, construction, clinic design and equipment selection, establishment of accounting systems and billing procedures and training of office support personnel, processing of accounts payable, operational direction, auditing of regulatory compliance, payroll, benefits administration, accounting services, legal services, quality assurance and marketing support.

Our typical clinic occupies approximately 1,000 to 5,000 square feet of leased space in an office building or shopping center.

Our typical clinic occupies 1,000 to 7,000 square feet of leased space in an office building or shopping center.

There are 14 clinics occupying space in the range of over 7,000 square feet to 13,500.square feet.

We attempt to lease ground level space for patient ease of access to our clinics.

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We continually assess the potential for developing new services and expanding the methods of providing our existing services in the most efficient manner while providing high quality patient care.

FACTORS INFLUENCING DEMAND FOR THERAPY SERVICES

Services provided in the industrial injury prevention services segment include onsite injury prevention and rehabilitation, performance optimization, post offer employment testing, functional capacity evaluations, and ergonomic assessments.

The majority of these services are contracted with and paid for directly by employers, including a number of Fortune 500 companies.

Other clients include large insurers and their contractors.

We perform these services through Industrial Sports Medicine Professionals, consisting of both physical therapists and specialized certified athletic trainers (ATCs).

FACTORS INFLUENCING DEMAND FOR PHYSICAL THERAPY SERVICES

We believe that the following factors, among others, influence the growth of outpatient physical therapy services:

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We focus our marketing efforts primarily on physicians, including orthopedic surgeons, neurosurgeons, physiatrists, internal medicine physicians, podiatrists, occupational medicine physicians and general practitioners.

In marketing to the physician community, we emphasize our commitment to quality patient care and regular

communication with physicians regarding patient progress.

We employ personnel to assist clinic directors in developing and implementing marketing plans for the physician community and to assist in establishing relationships with health maintenance organizations, preferred provider organizations, industry, case managers and insurance companies.

SOURCES OF REVENUE

Payor sources for clinic services are primarily managed care programs, commercial health insurance, Medicare/Medicaid and workers compensation insurance.

In marketing to the physician community, we emphasize our commitment to quality patient care and regular communication with physicians regarding patient progress.

SOURCES OF REVENUE FOR PHYSICAL THERAPY OPERATIONS

Payor sources for physical therapy operations are primarily managed care programs, commercial health insurance, Medicare/Medicaid and workers’ compensation insurance.

Commercial health insurance, Medicare and managed care programs generally provide coverage to patients utilizing our clinics after payment by the patients of normal deductibles and co-insurance payments.

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Bad debt reserves relating to all receivable types are regularly reviewed and adjusted as appropriate.

The following table shows our payor mix for the years ended:

The following table shows our payor mix for the years ended ($ in thousands):

December 31, 2020

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December 31, 2018

(Net Patient Revenues in Thousands)

Managed Care Programs

Commercial Health Insurance

Commercial Health

Medicare/Medicaid

Workers’ Compensation Insurance

Our business depends to a significant extent on our relationships with commercial health insurers, health maintenance organizations, preferred provider organizations and workers compensation insurers.

Workers' Compensation

Our physical therapy business depends to a significant extent on our relationships with commercial health insurers, health maintenance organizations, preferred provider organizations and workers’ compensation insurers.

In some geographical areas, our clinics must be approved as providers by key health maintenance organizations and preferred provider plans to obtain payments.

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for services provided in 2019, a 0.25% increase was applied to the fee schedule payment rates before applying the mandatory budget neutrality adjustment.

For services provided in 2020 through 2025, a 0.0% update will be applied each year to the fee schedule payment rates, before applying the mandatory budget neutrality adjustment.

For services provided in 2020 through 2025, a 0.0% percent update is expected to be applied each year to the fee schedule payment rates, before applying the mandatory budget neutrality adjustment.

However, in the 2020 MPFS Final Rule, CMS proposed an increase to the code values for office/outpatient evaluation and management (E/M) codes and cuts to other codes to maintain budget neutrality of the MPFS.

This change in code valuations would be effective January 1, 2021.

Under the proposal,

physical/occupational therapy services could see code reductions that may result in an estimated 8% decrease in payment.

In announcing this possible reduction in the applicable physical/occupational therapy codes, CMS indicated that it would further consider and address industry and provider concerns before finalizing the 2021 code values.

This change in code valuations was to become effective January 1, 2021 under the 2021 MPFS Final Rule, reimbursement for the codes applicable to physical/occupational therapy services were to be reduced by approximately 9% in the aggregate.

The 9% reduction in payment was addressed by the Consolidated Appropriations Act, 2021 (“Act”) signed into law on December 27, 2020.

Based on various provisions in the Act, we now estimate that the Medicare rate reduction for the full year of 2021 will be approximately 3.5% in aggregate.

Beginning in 2021, payments to individual therapists (Physical/Occupational Therapist in Private Practice) paid under the fee schedule may be subject to adjustment based on performance in the Merit Based Incentive Payment System (“MIPS”), which measures performance based on certain quality metrics, resource use, and meaningful use of electronic health records.

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The Bipartisan Budget Act of 2018, enacted on February 9, 2018, extends the 2% reductions to Medicare payments through fiscal year 2027.

Historically, the total amount paid by Medicare in any one year for outpatient physical therapy, occupational therapy, and/or speech-language pathology services provided to any Medicare beneficiary was subject to an annual dollar limit (i.e., the Therapy Cap or Limit).

For 2017, the annual Limit on outpatient therapy services was $1,980 for combined Physical Therapy and Speech Language Pathology services and $1,980 for Occupational Therapy services.

As a result of Bipartisan Budget Act of 2018, the Therapy Caps have been eliminated, effective as of January 1, 2018.

The Coronavirus Aid, Relief, and Economic Security (CARES) Act suspended the 2% payment reduction Medicare payments for dates of service from May 1, 2020, through December 31, 2020.

The Consolidated Appropriations Act, 2021 further suspended the 2% payment reduction until March 31, 2021.

Under the Middle Class Tax Relief and Job Creation Act of 2012 (‘‘MCTRA’’), since October 1, 2012, patients who met or exceeded $3,700 in therapy expenditures during a calendar year have been subject to a manual medical review to determine whether applicable payment criteria are satisfied.

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a separate $3,700 threshold is applied to the Occupational Therapy.

The MACRA directed CMS to modify the manual medical review process such that those reviews will no longer apply to all claims exceeding the $3,700 threshold and instead will be determined on a targeted basis based on a variety of factors that CMS considers appropriate The Bipartisan Budget Act of 2018 extends the targeted medical review indefinitely, but reduces the threshold to $3,000 through December 31, 2027.

The Medicare Access and CHIP Reauthorization Act of 2015 (“MACRA”) directed CMS to modify the manual medical review process such that those reviews will no longer apply to all claims exceeding the $3,700 threshold and instead will be determined on a targeted basis based on a variety of factors that CMS considers appropriate The Bipartisan Budget Act of 2018 extends the targeted medical review indefinitely, but reduces the threshold to $3,000 through December 31, 2027.

For 2028, the threshold amount will be increased by the percentage increase in the Medicare Economic Index (“MEI”) for 2028 and in subsequent years the threshold amount will increase based on the corresponding percentage increase in the MEI for such subsequent year.

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In addition, the MCTRA directed CMS to implement a claims-based data collection program to gather additional data on patient function during the course of therapy in order to better understand patient conditions and outcomes.

All practice settings that provide outpatient therapy services are required to

include this data on the claim form.

All practice settings that provide outpatient therapy services are required to include this data on the claim form.

Since 2013, therapists have been required to report new codes and modifiers on the claim form that reflect a patient’s functional limitations and goals at initial evaluation, periodically throughout care, and at discharge.

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Statutes, regulations, and payment rules governing the delivery of therapy services to Medicare beneficiaries are complex and subject to interpretation.

We believe that we are in compliance in all material respects with all applicable laws and regulations and are not aware of any pending or threatened investigations involving allegations of potential wrongdoing that would have a material effect on our financial statements as of December 31, 2019.

We believe that we are in compliance, in all material respects, with all applicable laws and regulations and are not aware of any pending or threatened investigations involving allegations of potential wrongdoing that would have a material effect on the our financial statements as of December 31, 2020.

Compliance with such laws and regulations can be subject to future government review and interpretation, as well as significant regulatory action including fines, penalties, and exclusion from the Medicare program.

For 2019, net patient revenue from Medicare accounted for approximately $119.4 million.

For year ended December 31, 2020, net patient revenues from Medicare were approximately $101.6 million.

REGULATION AND HEALTHCARE REFORM

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However, if the OIG believes we have entered into a prohibited contractual joint venture, it could have an adverse effect on our business, financial condition and results of operations.

Although the business of managing physician-owned physical therapy facilities is regulated by the Fraud and Abuse Law, the manner in which we contract with such facilities often falls outside the complete scope of available Safe Harbors.

Although the business of managing physician-owned and hospital-owned physical therapy facilities is regulated by the Fraud and Abuse Law, the manner in which we contract with such facilities often falls outside the complete scope of available Safe Harbors.

We believe our arrangements comply with the Fraud and Abuse Law, even though federal courts provide limited guidance as to the application of the Fraud and Abuse Law to these arrangements.

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Proof of intent to violate the Stark Law is not required.

Physical therapy services are among the designated health services.

Physical therapy and occupational therapy services are among the “designated health services”.

Further, the Stark Law has application to our management contracts with individual physicians and physician groups, as well as, any other financial relationship between us and referring physicians, including medical advisor arrangements and any financial transaction resulting from a clinic acquisition.

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These state laws may cover all (not just Medicare and Medicaid) patients.

As with the Fraud and Abuse Law, we consider the Stark Law in planning our clinics, establishing contractual and other arrangements with physicians, marketing and other

activities, and believe that our operations are in compliance with the Stark Law.

As with the Fraud and Abuse Law, we consider the Stark Law in planning our clinics, establishing contractual and other arrangements with physicians, marketing and other activities, and believe that our operations are in compliance with the Stark Law.

If we violate the Stark Law or any similar state laws, our financial results and operations could be adversely affected.

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We cannot reasonably predict what impact the adoption of federal or state healthcare reform measures or future private sector reform may have on our business.

The healthcare industry, including the physical therapy business, is highly competitive.

The physical therapy business is highly fragmented with no company having a significant market share nationally.

We believe that we are one of the third largest national outpatient rehabilitation providers.

The healthcare industry, including the physical therapy business, and the industrial injury prevention services business are highly competitive.

The physical therapy business as well as the industrial injury prevention services business are both highly fragmented with no company having a significant market share nationally.

We believe that we are one of the largest national outpatient physical therapy services providers.

Competitive factors affecting our business include quality of care, cost, treatment outcomes, convenience of location, and relationships with, and ability to meet the needs of, referral and payor sources.

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Such laws require providers to adhere to complex reimbursement requirements regarding proper billing and coding in order to be compensated for their services by government payors.

Our compliance program requires adherence to applicable law and promotes reimbursement education and training;

however, a determination that our clinics billing and coding practices are false or fraudulent could have a material adverse effect on us.

Our compliance program requires adherence to applicable law and promotes reimbursement education and training; however, a determination that our clinics’ billing and coding practices are false or fraudulent could have a material adverse effect on us.

As a result of our participation in the Medicare and Medicaid programs, we are subject to various governmental inspections, reviews, audits and investigations to verify our compliance with these programs and applicable laws and regulations.

In addition, our Corporate Integrity Agreement requires annual audits to be performed by an independent review organization on a small sample of our clinics, the results of which are reported to the federal government.

See -Compliance Program – Corporate Integrity Agreement.

In addition, our Corporate Integrity Agreement, which expired in February 2021, required annual audits to be performed by an independent review organization on a small sample of our clinics, the results of which were reported to the federal government.

See “-Compliance Program – Corporate Integrity Agreement” for more on the Corporate Integrity Agreement (“CIA”).

Managed care payors may also reserve the right to conduct audits.

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fines penalties and/or revocation of billing privileges for the affected clinics;

expansion of the scope of our Corporate Integrity Agreement;

the imposition of a new Corporate Integrity Agreement;

exclusion from participation in the Medicare or Medicaid programs or one or more managed care payor network;

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In addition, the Board has created a Compliance Committee of the Board (“Compliance Committee”) whose purpose is to assist the Board in discharging their oversight responsibilities with respect to compliance with federal and state laws and regulations relating to healthcare.

We have issued an Ethics and Compliance Manual and created compliance training materials, hand-outs and an on-line testing program.

We have issued a Compliance Manual and created compliance training materials, hand-outs and an on-line testing program.

These tools were prepared to ensure that every employee of our Company and subsidiaries has a clear understanding of our mutual commitment to high standards of professionalism, honesty, fairness and compliance with the law in conducting business.

These standards are administered by our Chief Compliance Officer (“CCO”), who has the responsibility for the day-to-day oversight, administration and development of our compliance program.

to reflect the on-going compliance focus areas which have been identified by management, counsel or the Compliance Committee.

The CCO, internal and external counsel, management and the Compliance Committee review our policies and procedures for our compliance program from time to time in an effort to improve operations and to ensure compliance with requirements of standards, laws and regulations and to reflect the on-going compliance focus areas which have been identified by management, counsel or the Compliance Committee.

We also have established systems for reporting potential violations, educating our employees, monitoring and auditing compliance and handling enforcement and discipline.

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These committees meet in the facilities and function as advisors.

We have in place a Risk Management Committee consisting of, among others, the CCO, the Corporate Vice President of Administration, and other legal, compliance and operations personnel.

We have in place a Risk Management Committee consisting of, among others, the CCO, the Vice President of Human Resources, and other legal, compliance and operations personnel.

This committee reviews and monitors all employee and patient incident reports and provides clinic personnel with actions to be taken in response to the reports.

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Educating Our Employees.

We utilize numerous methods to train our employees in compliance related issues.

All employees complete an initial training program comprised of numerous modules relating to our business and proper practices.

We utilize numerous methods to train our employees in compliance related issues, including an online learning management system.

All employees complete a comprehensive training program comprised of numerous modules relating to our business and proper practices when newly hired and annually thereafter.

The directors/administrators also provide periodic “refresher” training for existing employees and one-on-one comprehensive training with new hires.

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Compliance staff will remain in contact with the director/administrator while the clinic is implementing compliance standards and will provide any assistance required.

All new office managers receive training (including Medicare, regulatory and corporate compliance, insurance billing, charge entry and transaction posting and coding, daily, weekly and monthly accounting reports)

from the training staff at the corporate office.

The corporate compliance group will assist in continued compliance, including guidance to the clinic staff with regard to Medicare certifications, state survey requirements and responses to any inquiries from regulatory agencies.

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During these audits, particular attention is given to compliance with Medicare and internal policies, Federal and state laws and regulations, third party payor requirements, and patient chart documentation, billing, reporting, record keeping, collections and contract procedures.

The audits typically are conducted on site and include interviews with the employees involved in management, operations, billing and accounts receivable.

The audits are conducted on site or remotely and include interviews with the employees involved in management, operations, billing and accounts receivable.

Formal audit reports are prepared and reviewed with corporate management and the Compliance Committee.

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Corporate Integrity Agreement.

We also perform certain additional compliance related functions pursuant to the Corporate Integrity Agreement (Corporate Integrity Agreement or CIA) that we entered into with the OIG.

The CIA, which became effective as of December 21, 2015, outlines certain specific requirements relating to compliance oversight and program implementation, as well as periodic reporting.

In addition, pursuant to the CIA, an independent review organization annually will perform a Medicare billing and coding audit on a small group of randomly selected Company clinics.

Our Company Compliance Program has been modified so as to comply with the requirements of the CIA.

The term of the CIA is five years.

We also performed certain additional compliance related functions pursuant to CIA that we entered into with the OIG.

The CIA, which became effective as of December 21, 2015, and expired in February 2021, outlined certain specific requirements relating to compliance oversight and program implementation, as well as periodic reporting.

In addition, pursuant to the CIA, an independent review organization annually performed a Medicare billing and coding audit on a small group of randomly selected Company clinics.

Our Compliance Program was modified so as to comply with the requirements of the CIA.

The term of the CIA was five years and expired in February 2021.

The CIA was entered into as part of the settlement by one of our Subsidiaries with the U.

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The Subsidiary no longer conducts any business.

At December 31, 2019, we employed approximately 5,400 people, of which approximately 3,200 were full-time employees.

At that date, no Company employees were governed by collective bargaining agreements or were members of a union.

We consider our relations with our employees to be good.

In the states in which our current clinics are located, persons performing designated physical therapy services are required to be licensed by the state.

Based on standard employee screening systems in place, all persons currently employed by us who are required to be licensed are licensed.

We are not aware of any federal licensing requirements applicable to our employees.

Our strategy to acquire physical therapy practices, develop outpatient physical therapy clinics as satellites within existing partnerships, acquire industrial injury prevention businesses, and to continue to support the growth of our existing businesses requires a talented workforce that can grow with us.

As of December 31, 2020, we employed approximately 4,630 people nationwide, of which approximately 2,550 were full-time employees.

It is crucial that we continue to attract and retain top talent.

To attract and retain talented employees, we strive to make our corporate office and all of our practices and businesses a diverse and healthy workplace, with opportunities for our employees to receive continuing education, skill development, encouragement to grow and develop their career, all supported by competitive compensation, incentives, and benefits.

Our clinical professionals are all licensed and a vast majority have advanced degrees.

Our operational leadership teams have long-standing relationships with local and regional universities, professional affiliations, and other applicable sources that provide our practices with a talent pipeline.

We provide competitive compensation and benefits programs to help meet our employees' needs in the practices and communities in which they serve.

These programs (which can vary by practice and employment classification) include incentive compensation plans, a 401(k) plan, healthcare and insurance benefits, health savings and flexible spending accounts, paid time off, family leave, education assistance, mental health, and other employee assistance benefits.

We invest resources to develop the talent needed to support our business strategy.

Resources include a multitude of training and development programs delivered internally and externally, online and instructor-led, and on-the-job learning formats.

We expect to continue adding personnel in the future as we focus on potential acquisition targets and organic growth opportunities.

Beginning in March 2020, we have supported our employees and government efforts to curb the COVID-19 pandemic through a multifaceted communication, infrastructure, and behavior modification and enforcement effort:

Establishing clear COVID-19 policies, health and safety protocols, and routine updates to our employees and patients;

Increasing cleaning protocols and hand hygiene across all locations;

Providing additional personal protective equipment and cleaning supplies;

Implementing protocols to address actual and suspected COVID-19 cases and potential exposures;

Limiting non-essential travel for all employees;

Adjusting schedules and workload to permit remote working where possible;

Decreasing density, increasing social distancing and restricting visitors in our clinics and offices for employees working onsite;

Requiring masks to be worn by all individuals in all locations.

Additionally, due to the impact of COVID-19 on our operations, we have generated efficiencies in staffing, including limiting hiring to critical business roles, reducing scheduled hours, furloughs, and reductions-in-force.

Through our employees' commitment to following operational protocols and their continued efforts to provide quality services to our patients, we have seen much of the workforce and our operations return to pre-pandemic levels.

Throughout 2020, we conducted approximately 2,300 furloughs and reductions-in-force and have seen approximately 1,200 of these employees or 52%, return back to work.

AVAILABLE INFORMATION

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Compared sentence by sentence after normalising whitespace, quotation marks, case and digits, so re-formatting and restated figures do not read as changed language. Wording changes appear as one removal and one addition. The current filing and the prior one are authoritative.

What changed 10-K

Item 1. Business