CareCloud, Inc. (CCLD) Earnings Call Transcript & Summary

Hello. Welcome to this series hosted by Ladenburg Thalmann. Before we begin, I would like to let you know that disclosures related to CareCloud can be viewed in our most recent report as well as by contacting me, Destiny Hance at [email protected]. Additionally, for any questions or concerns, please e-mail me. With that, I'll hand it over to Jeff Cohen, Managing Director, Equity Research. Jeff, please go ahead.

Thanks, Destiny, and thanks, everyone, for joining us. So with us today, we have the leadership team of CareCloud. We're happy to be joined by Hadi Chaudhry, CEO and President of the company; as well as Bill Korn, CFO of the company. So thank you both for joining us, and we look forward to a nice discussion. I guess I'll start off by just throwing out to you, if you could walk folks through the history of the company, the when, the where and the how as far as the past, now it's been 8 years, if I'm not mistaken.

Yes. Thanks, Jeff. Thanks for including us. So we'll give everybody a little bit of history. So I'm Bill Korn, I'm CareCloud's CFO. CareCloud was started back 22 years ago by Mahmud Haq. His wife is a doctor and he basically started the company thinking about how to solve the problems of her practice and what are the things that keep physicians up awake at night. It starts with making sure you get paid, making sure you take care of all the forms and insurance and documenting your records, and he was looking for a solution for his wife's practice. And ultimately, in that classic entrepreneur spirit said, "You know what, I think I can do this better than anybody else out there." And so the company was born. I joined the firm back in 2013. At the time, we were a $10 million company and Mahmud said, "Bill, all we need is a CFO, and we can be public in 2 months." So I laughed, but we -- but I like the idea and I like the team that we had. We bought 3 companies on the day of our IPO, which was back in July of 2014. And clearly, we were a little bit small for a traditional NASDAQ IPO with $10 million of trailing revenue. But 17 acquisitions since the time that we've gone public, and we've really grown. So today, we're a $140 million company. At the time of the IPO, we were known as Medical Transcription Billing Corporation because 75% of our revenue came from medical billing. Well, we changed our name about 2 years ago to CareCloud. In part, it was a good name of a company that we bought in 2020. And by now, 84% of our revenue is technology-enabled services. So CareCloud really does a better job of describing what we do. I think you're on mute Jeff.

Sorry about that. So maybe you can walk us through a little bit of how time progressed and how the companies were tucked in and folded and as far as your emphasis on the technology and what new platforms and technology began to become assembled, so producing kind of an offering of different products that are available. And then talk a little bit about the backbone as well as your personnel and some of the economic advantages and geographic advantages.

Sure. I'll do some of it. And Hadi can do some of it. I mean, Hadi -- I can give you a little more history because I've only been with the company now for 9 years, but Hadi was helping start the technology 20 years ago. I think the -- when the company was founded, the initial problem of doing the billing was one that Mahmud would recognize could be done by people, but the right way to do it was to add the technology even on the billing end and make the people productive. Well, Mahmud is a U.S. citizen and the company is headquartered in the U.S. From the beginning, I think he recognized there was an opportunity to use a global team and to take advantage of people who could do work and do it a lot more cost effectively. So I think that's been a core element of our business from the beginning. When we think about M&A, we buy customers. I mean sometimes we've gotten some technology, which has often been a little more on the side. But at the end of the day, when we look at an acquisition, it's the relationships with the customers. And we look at this and say, "If we can acquire those relationships cheaper than we could do so through organic sales and marketing or cheaper than our competitors can do through organic sales and marketing, well, that's a good way to grow." And when we think about developing technology, most of the technology we have, we've developed ourselves. We have 500 people in our technology team at this point, mostly overseas, people who have developed everything from electronic health records to patient portals. We developed telemedicine back in 2019 and added it to the platform. And again, it's hard to believe, but if you went back 3 years ago and you asked people about telemedicine, the doctors weren't so interested. They weren't getting reimbursed. The patients weren't so interested because they're like, "Well, why would I do a Zoom call or the equivalent thereof if I could go see my doctor in person?" And so I think from the beginning, we've always felt the opportunity to be on the leading edge of the technology and to think about how to serve our practices and help them serve their patients. So Hadi, you joined the company initially in more of the technology area. So maybe you can give us a good perspective here.

Thank you, Bill, and thank you, Jeff, and thank you, everyone, for joining us today. So Bill -- as Bill mentioned, I joined in 2002, and I was the manager of IT. And the first goal was or the target for me was to establish an IT department. The whole vision was when Mahmud Haque founded the company, they're taking this conventional way of doing medical billing and transforming that into a more technology-based revenue cycle management product or solution. And when it comes to not only just the revenue cycle piece or the medical billing piece is there are too many other pieces that at that time were completely disintegrated in this -- in the health care practice market, whether it is the medical transcription, medical billing, there is a different practice management software, if there was any that a practice was using. And the EHRs was in the very infancy stages or the concept of the EHR was being adopted. So right after that, we launched our first internal medical billing system initially, which was transformed or transitioned into a practice management system somewhere around 2003, 2004 time frame. In 2005, we launched our first EHR platform. It was at that time was the client server model. And since then, now we are on the third generation of our EHR platform, which is a cloud-based -- fully cloud-based EHR platform, a certified product from the most recent certifications, compliance, whether it's the CURES Act and the like. So that's from the technology road map perspective. So we are not new to this platform or the technology. And in addition to that, then on the EHR side, as an example, some of the acquisitions we have done like CareCloud, we were able to fold another EHR system into a good product suite. So on EHR that we already have since 2005, which is today known as talkEHR, which we think is the best -- is best suited for small to medium-sized practices segment. And as an example, the core cloud core EHR platform, we believe is best suited for medium-sized to the enterprise space and the large medical groups. The one advantage, and I think you did ask a question, Jeff, in terms of our advantage on the employees, so we have today about 4,000 global employees -- over 4,000 global employees with about over 500 people in IT and R&D. So one differentiator -- one area that we focused on in addition to just keep on developing the off-the-shelf solutions, if you have -- you could have a very best practice management and the EHR solution for a small to medium-sized practice space. But when it comes to the enterprise space, many times because of their internal workflows, the off-the-shelf solution cannot best fit their needs. And because of our extensive -- the team, the IT R&D team and because of the global presence, we can still manage to have those team members and can still can offer these small customizations in addition to off-the-shelf solution at a much better price point, we are able to effectively do that.

Got it. That's super helpful. And could you talk about as the offerings have expanded dramatically over the last number of years, some organically driven and some M&A-driven. Could you talk about -- are there areas which you see today where you're lacking or don't have a competitive offering? Or have you achieved most of that and also tie that in with the M&A from the company? More recently, do you think about M&A as far as gaining the customers out there in the marketplace? Or are you thinking about potential M&As gaining technology that's available?

We tend to think of it really more from the customer perspective. And I'll give you an example. We talked to a lot of companies who say, "I've got great technology. I mean I've spent $3 million. I think it's worth $30 million." How much is your revenue? "Well, next year, I'm going to do my first $1 million of revenue. But I think I'm worth $30 million." And we look at this, and we'll say, you know what, if they developed it for 3, I bet with our team, we could probably develop it for half of that. And why would I be thinking of paying 30. So it's very hard for us to get excited about a pure technology play. And in fact, Again, I've spent a lot of my career in growing technology companies. 10 years ago, it was IBM, but a lot of it was companies that we're growing. The challenge is when you buy technology and you integrate it, sometimes that's harder than building it yourself. And I've also seen technology companies where you've got the technologists sort of saying, "Here's what I think the customer wants." Now if that technologist is Steve Jobs, that works really well. If not, it usually doesn't turn out so nicely. And I think, Jeff, you've even seen -- years ago, you saw our software our first client, the founder's wife's practice, and you actually saw real users using it. And in some respects, when it's the nurses and the doctors and you're seeing the patients signing in on the patient portal, you get to see what the real users want, and that's the way to develop technology. So that's how we've always thought about it. .

Hadi, your thoughts on the technology?

Sure. And if we just -- just to be a little more specific, if you think about it, our core technology today is -- one is the electronic health record system. The second one is practice management. The whole set of core solution is around the patient experience management. And the fourth to what we call our ability to customize any of these 3 according to the needs of the practice or coming up with some other applications which might be needed for the workflow of that specific practice. Then we have a layer that sits on top of these core technology platform, which is our technology-enabled revenue cycle management company -- I'm sorry, the technology-base-enabled revenue cycle management. Then there are a number of other small pieces of technology in some of those -- most of those were internally developed and some of those which became part of us through an acquisition, just I could remember I can talk about 2 more prominent ones. One is the -- our RPA bots, robotic process automation bots. And the second one was our Precision BI business intelligence platform. These 2 technology pieces were part of the Meridian acquisition we did earlier. And now with the help of these 2 -- let's talk about RP as an example, there could be many repetitive mundane tasks, which today otherwise would have been done by someone -- a person. And now those repetitive tasks, with the help of these bots, can be done systematically. A very basic example, a denial came in, insurance rejected a claim for looking for additional medical documentation as an example. The bot can pick it up, go and pull the medical documentation automatically from the hospital or any other EHR or our EHR platform, attach it to the claim and send it out automatically. So the whole process can be done completely by that virtual employee versus a physical employee. Same could be -- a virtual bot could be there, checking eligibility and lining up the patients for either approved further visit or a prior authorization is needed before the visit is ready to be taking place. So a number of these things can be done with the help of the RPA bots that we have implemented today. The next -- and we'll talk about it more later in the -- during the webinar is our digital health initiatives since the whole health care industry is transforming towards this next generation of health care, that's what we are calling, which is which will be more dependent on digital health solutions as well as the value-based care models. And we're going to talk about it further. But that's one of our -- another core focus is today from the future perspective.

Got it. I wanted to jump over to a couple of questions on the commercial side, if you could talk about. It seems like the past number of years, the Meridian acquisition also be a CareCloud become, I would call it, more of a commercial focused company, meaning it appears if you have more visible our reach and more of a commercial backbone and organization that's reaching a number of different areas. Could you talk about that and how that developed, how that came to be and what that may look like going forward?

Sure. And I'll say from the time of the IPO, and we talk about our growth, people would say, "Bill, it's great that you're growing 35% a year. But how much of that is organic?" And the truth is until a few years ago, we were spending 2% to 3% of revenue on sales and marketing. And what happens when you spend 2% of revenue on sales and marketing? You don't wind up with an exciting organic growth rate. But at the time that we bought CareCloud, whose name we took, we picked up a core of a sales and marketing team. And I'd say before that, we had started, but we never really got the traction. And now we had a couple of good people, and we use that to really branch out and increase our spending. So we're now spending over 6% of revenue on sales and marketing. We've now got a total of 55 people worldwide in sales and marketing, half of them offshore, half of them are onshore. And we're now actually signing new clients on a regular basis, doing partnerships all the time and seeing real positive net organic growth. And again, even the name, I'd say when you're thinking about a sexy name, a name of MTBC Inc., I can't tell you how many times people were trying to figure out what order the letters of that go in and what they meant. And now all of a sudden, there's a name CareCloud, and they can think about that, and it resonates. And so as you say, there's a lot more commercial focus than there ever was before, and we think it's good. And that doesn't mean that we've abandoned acquisitions. We continue to be looking for deals. We don't happen to close one this year. But we're always looking for opportunities, but we look forward to being in a position where we can deliver great organic growth quarter after quarter. And every once in a while, we do a game-changing deal and it ratchets it up even further. So that's better than just having to wait for the -- for M&A as the only source of new business.

Hadi, sorry to interrupt, has that also -- I don't want to interrupt you, but I want to just tack on one more question, which has the focus on the sales and marketing and commercial side, fuel the technology side and the internal R&D side as well?

Yes, just to support what Bill had just mentioned. So we had the second quarter of 2022 and the third quarter being the 2 record booking quarters in terms of the annual revenue -- recurring revenue client bookings, some over $5 million [indiscernible] and over $7 million in the third quarter, and we are expecting, anticipating another exciting fourth quarter. Although we're still not closed, but we have some good deals that we have been able to sign. But yes, 100%. So this is the closing or the booking that is coming. And on the other side, the acquisition -- the improvement that we have been able to bring in from the prior acquisition and if any other, the right acquisition comes, we will acquire them. But the organic growth strategy seems to be working, and you should be able to see more and more organic revenue coming in into the next years.

And think about organic as having 2 components today. And again, from having no organic, you've got a team focused on new customers. But now for the first time, we've got CareCloud Wellness. We've got a new offering that's really exciting that we're able to cross-sell to existing customers. And in some respects, that's -- this is the CFO's dream is that every quarter, you're getting more money out of the existing customers while you're getting new customers that are signing up. And so it's a -- and so therefore, as we talk to doctors and we've thought about what they need and we've looked at the environment, that has allowed us to develop these new offerings, which I think we can share with you all the excitement that we have. One of them is called chronic care management. And the whole notion with chronic care management is that if you're a patient and you've got a chronic condition, and you wait to really have symptoms, you're probably winding up in the hospital, and it's expensive. And for the last couple of years, Medicare has been thinking about this, and it was only a few months ago that they really increased the reimbursement rates and said. "You know what, it's actually cheaper for us when we are paying the cost. We'd rather pay for the preventive visits and make sure that we nip this in the bud and keep the patient healthy." And that's led us to develop a whole chronic care management offering. Sort of the -- and when you think about that offering, you're looking with people with diabetes or asthma or some chronic condition and somebody is talking to them. And it's maybe it's a 10-, 15-, 20-minute conversation, and it could be on video like this. But you know what, sometimes the patient isn't comfortable, and it needs to be a phone call, that's okay, too. You can just check in, how are they doing? Everything is fine. That's great. Let's set up a time for next month. In your case, maybe things -- maybe it is time for you to go see the specialist. Let's just get you an appointment right now, and let's get you in before things get bad. And so developing the technology to do that with people remotely, I think that's really interesting. And along with that, we've added a second offering, remote patient monitoring. So now we've got, again, people with chronic conditions where there's a device that can check up on how they're doing. So a classic example is the automated blood pressure cuffs. And again, think about what would happen if you were the doctor and 300 of your patients every day sent in their blood pressure readings. What would you do with it? I mean you never have a chance to look at it. You never really spot trends. I mean that's an offering that's ripe for technology because we can go look at that, we can compare you to where you were yesterday, where you were the day before to your population. And so we can spot trends and of those 300 readings, there's one that needs a follow-up. Great, we can figure that out. And again, there's now opportunities to get reimbursed for the device, to get reimbursed for those follow-up visits. And to us, that's a real win all around. It's a win for the patient because the patient stays healthier because the last thing anybody wants is to wind up in the hospital sick. It's a win for the doctor because as we get reimbursed, we're sharing some of the reimbursement with the doctor, and we're doing the work. They're not doing the work. So they're just getting free money. And it's a win for the payer because even though they're paying for these visits, they're paying less than they would if the patient got sick, and they had to get them back to the health again. So to me, that's a win all around.

Got it. So talk about that -- the Wellness platform. And maybe -- so you've got the chronic care management thus far and you have remote patient monitoring thus far. Are there other pieces that fall under the Wellness platform? Talk about that a little bit and then talk about the Wellness platform from a commercial standpoint if that offering -- is it more of a B2B sale to larger entities such as IDNs, hospitals, payers or even government entities? Or is it also something that's very appropriate for smaller scale physician practices?

Great. Thanks, Jeff, for the question. So from the Wellness platform today, yes, these are the 2 solutions that we offer under the Wellness brand. One is the chronic care management and the second one is the remote patient monitoring. So for any of these 2, if you just step back and think about it, there are 3 main areas of this solution/platform. One is the technology side. So finding the right platform, dashboards integrated into the existing workflows, whether it's an EHR, where there is an ability to document the chart properly for chronic care, reminding the provider to take appropriate next steps in case of anything -- any action that needs to be done. In the case of the remote patient monitoring, this technology side means integration with the devices. The capability of the system to collect the data from the devices over the Internet, over the Bluetooth and then being able to consolidate the data and flag the patients where attention is needed. So we have been already -- since the last 2 decades, have a strong -- we have a strong team of -- from the technology standpoint, we kept on developing more and more products and related technological products. The second piece is the revenue cycle piece. So now you have been able to perform technologically completed everything, but now the second piece is the revenue cycle. You won't be able to collect or reimbursed unless and until you submit the claim at the right time to the right payer and keep track of it, do the denial management and also keep an eye on the right reimbursements. We have the 2 decades of experience. There's a rule-based engines. There are many things automated, which help us achieve the best possible reimbursement for all the functions performed under this Wellness, whether it's chronic care or remote patient monitoring. And then the third piece is the care managers. And in the care managers, there we have the certified according to the requirements under the CMS guidelines, a set of care managers who, instead of the providers, they are the one who engage the patient -- engage the eligible patient who needs additional care. They talk to the patient, they guide the patient and then document everything into the system. And then at a certain point, they flag it to, okay, now the claim can be sent to the insurance company on the commercial side. That's the financial collection. That's the revenue improvement for the client. What we have seen that today is somewhere it can improve -- if a practice adopt to both of these 2 pieces, whether it's chronic care and remote patient together, and improve on the revenue from somewhere between 20% to 40%, 45%. And this is just the hard core -- the revenue I'm talking about. On the other side, there is a better patient outcome. The patient satisfaction improves. The hospitalization rates are decreasing. So that helped them even deliver better care to the patient and getting them prepared for the future health care challenges more towards the paper performance models, value-based care models. So the other second part of your question, which is, is it the B2B or -- so, so far, what we have done is we have a tremendous opportunity today into our existing client base. We believe by looking at the numbers, conservative numbers at about less than 50% penetration rate. We believe we should be able to generate up to $50 million in annualized recurring revenue from the existing client base for chronic care and remote patient monitoring over the next few years. So that's, so far, what we have approached. We have recently started to open it up and start running campaigns to sell it to the other practices in the industry who may not be getting the rest of the services from us today. But when we're presenting the chronic care or the wellness platform, we even have an opportunity to get those clients on as an end-to-end because that's where the real value lies for practice as well as for us.

And how are those potential customers wrestling with the "who's paying for it" question when they talk about that and maybe lead that into, well, the larger question, the elephant in the room is the payers out there in the U.S. and how swiftly and how accommodating they'll be at recognizing and paying for technology solutions such that they can provide better care and obviously they can save money.

That's a great question because I think if you think about this ramp chronic care management was started and somewhere in 2016 time frame. So initially, it was just the Medicare who was reimbursing for chronic care management encounters. And the requirement to a so strict, let's say, the only the doctor can, as an example, can perform the discussion with the patient. And the nurse practitioner can do it, then there is under the supervision can be done. So they, on one side, they keep relaxing the requirements for the chronic care management. On the other side, there have been a consistent improvement and specifically, as Bill mentioned, early this year, the rate significantly improved from the reimbursement standpoint from -- for chronic care management. On the other side, more and more insurances have now started to pay for chronic care management and these programs and the like. And now when it comes to who will be paying and how to make sure they get paid correctly, that's where our revenue cycle management capability comes in. We keep track of it. So first of all, we look at the eligible patients who fall into that criteria where the chronic care management or remote patient monitoring services can be performed after eligibility, identifying those patients, then we engage the patients and we make sure we bill it to the right insurance and get reimbursed. For the insurances who are, let's say, as an example, not reimbursing for those visits, then we leave it this decision up to the provider. If they still want us to go ahead and still perform the visit because in the bigger picture, you are still improving the overall health of the patient, which can trigger even the next possible visit for the patient. So on one side, the overall health is improving and the next encounter can still -- on the commercial side, can still generate some revenue for the practice.

So you don't necessarily think of it as only per patient per month charge to whoever might be paying?

Okay. No, that's good. No, we are not at this point. When it comes to the chronic care management and the remote patient monitoring today? No, we have not. I think you are more referring to the bigger picture where, as an example, under an ACO model or a value-based care model, where you're responsible to manage the lives of certain patients, and that's where the per patient per month model will come in. But at least until now, we are not focused on that -- on those models.

Okay. And then jump back on the previous question. maybe just your opinion about the payers out there in the U.S. and how they're thinking about this. They're more and more understanding the value of the technology. And how is that coming to fruition as far as the payment, both government and the private side?

I think they're -- at the end of the day, they're looking out for what's in their best interest. If it's cheaper to pay for these preventive visits and keep you healthy and they're going to pay less over time, that's the way they want to go. If it's more expensive, they're not going to be ready to write checks. And our belief is that we've got the right model because ultimately, improving the patient's health, that's got to wind up being the best -- most cost-effective way that you can do things. And so we look at this and say it's clear that this is the direction, and it's gratifying to see that Medicare and private insurance have been coming around to that over the last couple of years.

And just to extend on what Bill has said, I think it's more and more insurances have started to realize and on track to adapt to these new models. And the question is how long would it take. But eventually, they will get there -- may not be in the short term, but thinking about a few years from now, maybe next decade as an example, this decade we are in. They will not have a choice ultimately to adapt to more and accept to these standards. And at the end of the day, this whole thing is still have to be pushed towards the value-based care models, the pay-for-performance models. Take example of the telehealth as an example. Go back 3 years, 4 years, 5 years, there was very few insurance companies who were accepting telehealth visits. But now if you go even as a patient, sometime, I receive a call from my insurance saying, okay, do you have -- do you know you can use this app to schedule the telehealth visit and we will still cover and we'll pay for it. So I think that's -- to your point, Jeff, the evolution is coming. The insurances are still -- there are certain insurance who are denying and not accepting, but eventually they will get there. And absolutely became in this sector, in this space, a tailwind, accelerated some of those adaptability. And we foresee more and more of this conversion to be coming more rapidly in the future.

So would you describe that generally speaking as, in the U.S., we're still in the first quarter or maybe we're in the second quarter, and the payers and the government want to continue to garner data and information about is this really helping patients? And is this really saving money? Is this really tying into better care?

Okay. I think the fundamental -- the real, the first fundamental was the digitization, say, electronically saving the patient health record as an example. So the last 20 years, if you think about it from almost virtually no EHR to today, if you step into a doctor's office, hardly you will find a practice who is not using an EHR system. So that foundational step has been completed. Now on one side, there is an extensive focus towards the interoperability. If you think about the [indiscernible] network as an example, that's another initiative where the government and the CMS they want the data to be consolidated at a higher level from all the different EHR systems now. So that data is absolutely going to help and drive and take the further the decision for the health care industry. In terms of, let's say, should we call it, in the first or the second quarter, I think we are at the close to probably the end of the second quarter and 2 more quarters have to come. And if I look at it in the first half of the year, the first phase, I would say or the first transition was or the first phase of this was a computerization of the health records and bringing this -- the health providers onto a computer-based platform, that seems to have almost completed now the next level of advancement. The real objective behind this first set is about to come.

Got it. And how do you think about the complete category of digital health and maybe where you're currently positioned with your wellness offerings and where our competitors are aiming to position as well in that segment?

So on one side, if you think about Cures Act as an example, so there is a government -- one-side government initiative, which is pushing the vendors in the EHR space and even the practices, the health care providers on the other side to adapt to those changes. So that's how it's being pushed from the government side. The technology, if you think about, let's say, what we call the Internet of Medical Things, there are more and more devices that are coming in and introduced in the industry today because of the technological advancement, which has the capability of monitoring the data seamlessly and has the ability and the capability using the Internet to put the data into the cloud, which can be further consolidated and used, and the decisions can be taken, so that investment. And the third thing is the companies, as you're referring to, which are either providing just the remote patient monitoring services or chronic care management services. So we are trying to look at it as a one whole end-to-end. That's how what our initial from day 1 goal have been, a comprehensiveness unification. We are trying to find our more and more devices where we can brand them, our own branded devices, get them FDA approved, fetch the data, consolidate the data, keep on improving our EHR platforms to, on one side and keep on complying with the next industry requirements. We have started to focus on [indiscernible] and similar other interoperability solutions and then providing the revenue. Because at the end of the day, whatever you do, you still have to get the claim reimbursed on the commercial side to keep on running the business. So we cannot lose focus on the importance of the revenue cycle. So this comprehensiveness, I think it's still going to be the one of the differentiators for us.

Got it. That's very helpful. And then I'm going to jump on to something completely different. As far as your business segment via geographies out there, have you thought about or have you done some work as far as the European Union or any other RoW countries, Rest of World, Southeast Asia, South America, et cetera? Or in the shorter term, will you continue to be primarily focused domestically.

Short term, we see a lot of opportunity domestically and a lot of opportunity to grow. And it's always tempting to say, yes, I see another market, it's great. It just happens to be across an ocean. But in some respects, there are so many opportunities that are close to home that, that will probably be our primary focus at least in the short term. Now long term, I mean, we as a company, 80-odd percent of our workers, maybe more than that, are overseas. So I mean, we're a global business, and there certainly are a lot of commonalities in terms of the health care challenges that people face around the world. So long term, there's certainly going to be some opportunities to do things there. I'd say today, we're not going to let ourselves get distracted, but we're always thinking about those opportunities and where that might lead us into the next decade.

Right. And I think just on what Bill said, let me just share -- up to a certain extent that one of the things that to you towards your point that we were thinking or trying to do, leveraging the digital health technology or the telehealth technology. If you think about, we have 40,000 providers we are working with on the U.S. side. We have over global workforce. If we have 80% of the workforce offshore, there's an opportunity there from the patient standpoint. So if you are able to put a model together where we can have the U.S.-based, as an example, the providers help and support the patient in these countries, and there is an opportunity that does exist. We will share further information when the time comes when we think we started moving more extensively in a disciplined way towards that solution. But that's on our -- that's the one thing which is on table and it's being discussed, and we have taken some first baby steps, but we still have to -- a lot of things needs to be done.

Got it. Okay. I did want to visit briefly and Bill, maybe you can walk through some of these metrics, just big picture and nothing forward-looking. The company stands now at approximately $140 million of revenue. And maybe talk about some of the underlying metrics or from last year, the underlying metrics with the adjusted EBITDA metrics, which I believe were 16-ish percent approximately and some of the net income measurements and maybe cash flow metrics that folks may want to look at.

Yes, certainly. So -- and I'm going to give people a little bit of a high view, but I'd encourage you to look at our SEC filings, look at our Investor Relations website where you'll be able to see a lot of this stuff in good digestible earnings release or presentation format. And Jeff, as you said, we've given guidance this year that we're going to do $140 million to $143 million of revenue, $22 million to $25 million of adjusted EBITDA. And at one level, those numbers aren't dramatically different than they were in 2021. At another level, it's a huge milestone for us because we started the year knowing that we had 2 large hospitals, which each had been acquired before we inherited their contracts in 2020 when we bought -- one of the companies that we bought. So we knew that they've been acquired, and we knew it was really only a matter of time until they integrated with the companies that -- with hospitals that bought them. At the time that we did the deal, we didn't know where they going to be around for a year, where they're going to be around for a decade. But you do that sometimes, at some point, something was going to change. And for better or worse, each of them completed their integrations this year. And so that's 2 large hospitals where there was a lot of revenue in 2021 and $10 million less of revenue from those 2 in 2022. So we started the year not knowing when that might occur and also not knowing whether we will find an interesting acquisition opportunity. We sort of started out saying, I bet we'll find an interesting acquisition and will more than make up the difference. And we didn't find an acquisition on compelling enough terms, so we didn't do one in 2022. And yet we're still backfilling that revenue, backfilling it with new customers, backfilling it with new services. The company that we bought in 2021, medSR, which focuses really on the hospital space, we've been able to generate more business from that because we've been with us for a full year now. So that's allowed us to grow the revenue. Now at one level, you'd say 2023, you don't have that problem, right? But in fact, these 2 hospitals actually sort of left midyear. So I guess sort of a half year of revenue this year. So as I go into next year, I got the same phenomenon. Now the advantage is in January of 2022, I didn't know whether I was going to lose a month of revenue or a year of revenue. By now I know exactly what I'm going to lose in 2023. And yet I still feel very comfortable that we've got enough organic things going on that's going to more than make up for that, that will allow us to print a growth in revenue, a growth in EBITDA, a growth in cash flow. And again, maybe we'll find a great acquisition. That might add some gravy, but we don't need that in order to continue the focus. And I think for years, we've been EBITDA positive. I don't know, 5 years, 6 years, every single quarter, but EBITDA positive. Now for the last 5 quarters in a row, GAAP net income has been positive, and it's actually been over $1 million for each of the last 5 quarters. So a lot of people think, "Oh, gee, they have EBITDA, they don't really have GAAP net income." Well, actually, we do have GAAP net income now. But as a CFO, GAAP net income is interesting, but cash flow is what is actually really more interesting. And again, we drive positive cash from operations every single quarter. And it's good to be generating enough cash flow that you say every quarter, I don't need external sources of financing. So I might not like where my stock is at, but it doesn't matter. I don't need to sell shares at this price because I generate the funds that I need internally. And so it's nice to have the positive cash flow. And again, I foresee that, that positive cash flow is going to continue to grow throughout 2023. And it's a good position to be in as a company to do that.

That's fantastic. Hadi, do you want to add anything there? Or no?

No, I think Bill covered it really well. The only just one point. I think this real results of the organic growth, this engine has just started to fire on all cylinders. So the revenue realization, so whatever the revenue -- realized revenue that you will see in 2023, it's going to be much bigger in 2024 because by that time, all the -- so from the new signing and by the time the actual client will go live and start generating full -- revenue at full potential, there's a gap. So I think that's where the true picture of our organic strength will be, everyone will be able to see.

Right. And in 2024, you won't have the headwind of these 2 hospitals that sort of -- it hurt us in half a year in 2022, it will hurt for the first half of the year in 2023. By the time you get to 2024, you've got enough momentum coming from the new customers and the cross-selling that you'll be reporting some really exciting net organic growth rates, high single digit or maybe even better than that net organic growth rates. And again, that seems to me that's what everybody is always asking about.

And you made those comments in the context of no assumptions on the...

No assumptions on acquisitions, right. Right. And then maybe we'll find some interesting acquisitions. And again, we're always looking -- and the only reason we haven't done an acquisition for 18 months is we haven't found somebody that meets our hurdle, which I'll admit as the CFO, we set some pretty high standards. We look at a company and we say it has to be worth more to us than it is to them. We have to be able to -- before we buy the business, we have to have thought about how am I going to reduce the costs, improve the profitability, and I want to see in 3 or 4 years that I'm going to generate profits and cash flow to pay back my investment. And if I can do that, then I feel pretty confident that this is going to be an accretive deal. And look, you start thinking it's going to pay back in 3 to 4 years. Maybe it takes a little longer, and it takes 5 years, but that's okay. I'll contrast that with some of the companies that we see who say, I'm worth 5x revenue. And if you buy me, I'll have my first profitable year next year. How many years does it take if you're making zero profits to get back 5x revenue? That's a lot of years. And so we look at that and say, no, that's not for us. So we have to find companies where we feel that we can get a great return on our investment.

Got it. Destiny, did we have any other questions from the audience that weren't covered that you want to jump in with? Or are we good on that front?

We did have one question come in, and one of our viewers would like to know if the company focuses on any specific types of practices and typically the sizes of those practices. And I think this may be geared towards Wellness. Maybe they're asking, are you rolling out wellness into larger accounts? Or are some of your smaller practices also utilizing it?

Great question. And I think whether it's Wellness or any of our rest of the core technology platform or the rest of the services, revenue cycle services, we are addressing all the industry, the market segments today. 1 to 5 practices that typically for many companies to many other vendors, they cannot provide the service to 1 to 5 practices from the price point basis. They are not able to compete at the price because small practices, they cannot pay you a high percent on the revenue cycle services, and then the EHR license, then the practice management license. So it's a very attractive because of our global workforce and proprietary technology and 20 years' experience. We are very successful, already have been able to prove ourselves to be successful into 1 to 5 space. Then we have what we call, let's say, 5 to 20 doctor practices. We have 2 sets of EHR, the full suite of products and services that we have to offer. And then we have the clients in the 20-plus space. We have practices today, who have 2,500-plus clinicians. We have practices we have 500-plus providers. So we are working on all of these market segments today. And the other example of the 2,500-plus clinician I'm referring to, they're using our full technology today or most of the technology today with our end-to-end revenue cycle management services. So to answer -- summarize the answer, yes, our ability is there today to serve all the industry segments of the market. In the health system space, we are not competing with the health systems, whether it's Epic or Cerner or the Meditech and the like. But we do add value by doing the right integration and still being able to provide the end-to-end revenue cycle services from denial management, charge posting, payment posting and some of these other tools such as RPA. It still can work in those platforms. We have the Precision BI as an analytical tool, which can be used to crunch the numbers, take the reports and provide the business intelligence reporting sitting on top of Meditech as an example.

Okay. And we have one more come in as you were answering that. Can you discuss the early physician feedback you've received from wellness? And then I would also like to add what about patient feedback? How do patients feel about this? And how do they feel it helping their conditions?

That's a great question. And a few things. On the physician side, I think to ask, first of all, for the first time, we launched in second quarter, our physician has -- the first set of physicians are in the very early stage of going live, where now we have been able to start reaching out to the patients. So first of all, we do not have enough data. Having said that, we already have started to see some good stories. Financially, if I take example of at least one of the practices, we have seen the increase in their revenue by close to about 25%, 25-plus percent. So that's on the financial side. On the patient, we asked the very first initial calls are we need to help them understand why this call is important for them. And I was just talking to before the call with our head of chronic care remote patient to share with me some of the specific examples. And I can share 1 or 2 of the examples that might help us understand. Okay. As an example, a perfect example, a patient was suffering from hypertension and diabetes who often lands in an emergency, because his habit was if we ran out of the medicine, he looks at his symptoms, okay. I'm okay. Let me wait 20 more days. I just have to wait for my next visit, and then I can go and get the medicine. And many times, he ends up being in emergency because his blood pressure went up and gone out of control. Now because of this connection, our team was able to care managers, now check them in -- okay, you need a refill of the medicine. So now with the help of that care manager, the care manager was able to help connect to the doctor and the refill was done. And now we have not seen -- the same patient has not seen an emergency visit over the last 2 months as an example. So these are -- there are so many such examples where we see the -- from our care managers how they have been able to improve the patient lives. And this level example is, I think, is a perfect example. And if you think of for the people who are the hypertension people, it happens. If you're running out of the medicine, you have -- I'm okay, I'm feeling fine. I don't have a problem. That's -- let me wait for my next visit to get my refills. I hope that answers the question.

It did, and that was a wonderful example. Thank you. I don't see any more questions in the queue here. So Jeff, I'll hand it back to you.

I wanted to throw one more in just over the past year or so, if you have any commentary on specific segments and growth within segments. Obviously, besides GP or any type of general practitioners, are you seeing any particular strength within, say, endocrinology, cardiology, orthopedics, et cetera?

Right. I do not have any specific numbers with me right now. But yes, from -- as we are moving from small to large segments, yes, those are more specialized into. Yes, we do service -- today, about 80, 80-plus specialties, we service today. That does include cardiology, nephrology, orthopedic, physical therapy. One of our largest client in the physical and the speech therapy, we have 3,500-plus and they have been, I think, in 16-plus different states. So over the last few years, yes, there has been a change or a shift from small to medium practices towards the larger site, whether it's in terms of the revenue or in terms of the number of providers or even the different multiple locations implementation. And especially with the help of -- with our medSR division now, they have had -- they have been in business for the last 2 decades before we acquired them. In the last 2 years alone, they have done projects with about 100 different hospitals. If you think about the revenue cycle and the other services we offer, their RCM-related revenue, whatever it used to be before our acquisition, since we have acquired them this year, we already have closed the business over 3.5x more than what it was before the acquisition. And this 3.5x more business is coming because of the services now we have been able to add into that space. And the reason I'm giving this example -- in most of the cases, those are the large opportunities because we are performing these services into the health system space and which are the much larger clients, more complex specialties and the like.

Got it. That's very helpful. So I think we're running out of time. I have no other specific questions to ask. If there's any other additional points that you want to wrap up with, we would welcome that. And why don't you take that away, Hadi or Bill.

Sure. Thanks, everyone, for joining us and listening to us. You've got some questions that you want to learn more about us. I encourage people to look out to our IR website, which is ir.carecloud.com. Just for anybody who is interested, on Monday, we're hosting our first ever Analyst and Investor Day, which will be a virtual event and will be streamed on the web. So it will be 1 to 3 on Monday, and it will also be available on playback. So again, just go to ir.carecloud.com, you can hear us. I'm sure Jeff will ask us some good questions during the analyst question part of the presentation. So -- and it was to give you a chance not only to hear from Hadi and myself, but you'll get to hear firsthand from a number of the members of the management team. You'll hear a couple of our customers talk and who knows, maybe you'll even get a treat and see some of our offshore offices. Can't promise anything. You'll have to listen to find out.

Perfect. Thanks for that teaser, Bill. So without further ado, Hadi, thanks so much for your time and insight. And Bill, thanks so much for your time and insight, and we look forward to hearing more next week.

Yes. Thanks, Jeff and Destiny for including us today.

Super.

Thanks, Jeff. Thanks, Destiny. Thanks, everyone.

Have a great day.

You, too. Thanks.

Bye. This concludes our webinar. You may now disconnect.