Good morning, everyone. Welcome to the J.P. Morgan Healthcare Conference. My name is Anne Samuel, and I cover healthcare technology and distribution here at J.P. Morgan. We're thrilled to have Waystar with us. This is their first conference as a public company. Presenting this morning is going to be CEO Matt Hawkins. He'll do his presentation, and then we'll follow it up with Q&A. So with that, let me turn it over to Matt.
Thank you. Thank you. And good morning. I look forward to the Q&A portion. As Annie said, this is our first opportunity to present at J.P. Morgan as a public company. I've had the chance to present previously on the private company track, but my name is Matt Hawkins. I'm the CEO of Waystar. I helped form the company in 2017 with a fabulous group of people. And I feel so grateful and honored to be able to represent our whole team today in introducing Waystar to you and providing a bit of an overview of what we do. And so we'll jump right in and anticipate that we'll spend the second half of our discussion in Q&A. As we talk about Waystar, there are some foundational things we would love for you to know about us.
The first is that we are a software company purpose-built for healthcare to help transform the way that healthcare payments occur at a time when, as we'll talk about further in the presentation, there's a lot of commentary in broader society about what we can do to reduce the friction of payment, reduce the likelihood that a claim gets denied, and benefit providers and patients alike. The work that we do is mission-critical in nature. We are helping organizations understand their cash flow, the timing of payment, the likelihood that they will get paid. And once you put our software in place in an organization, there's a strong likelihood that we are there for a long period of time. Our gross revenue retention rates are 97%, and that's been the case over, I'll look back, over many quarters and years.
So we develop great relationships, in part because of the mission criticality of what we do and the ways that we help provider organizations be successful. We offer a cloud-based software platform, and we think that's really important because we're going after a large addressable market opportunity, as we'll talk about in a moment. And our ability to innovate and to keep pace with what's going on amongst the payers who are constantly looking to interact with providers, if we can deliver cloud software and deliver innovation that helps providers be successful as they interact with patients and with payers alike, then we help them win. And we are delivering hundreds of feature improvements to our cloud-based software platform in any given quarter. And by the way, I can't wait to show you a couple of screenshots that we have of our software.
I think you're going to find that it's beautiful, it's intuitive, and it's easy to use. So these advancements that we're making on a regular basis really mean a lot to the clients that we serve. We are deploying AI across the platform. That's another thing that we'd like for you to know about us. And we have been for over a decade. There's the opportunity to organize work and to prioritize work for an end user and to automate portions of a workflow. As provider organizations have end users that are constantly working to appropriately account for the patient interaction, then bill and collect and follow up with insurance companies and also with patients, what we find is that there's tremendous opportunity for us to leverage artificial intelligence to bring improvement to, to clarify and automate a bunch of workflow tasks there.
As I highlighted a moment ago, our work is mission-critical. We create enduring and long relationships with clients. We're pleased to be market leaders in client satisfaction and Net Promoter Scores. I'll show you a slide in just a moment that highlights the fact that the market is attesting to the fact that we're delivering value to them. Because we are, we create enduring relationships. The last thing I'll highlight is that we have a highly visible growth, durable growth business model. We talk about our long-term targets of low double-digit revenue growth and Adjusted EBITDA margin targets of about 40%. That durability, that ability to compound growth and then to use the proceeds of that growth in a very disciplined way to drive further innovation on the platform gives us confidence and a sense of momentum in what we're doing.
We were very intentional as we formed Waystar all the way back in 2017. We looked around the market and we thought at the time what the Wall Street Journal referred to as the supersizing of American healthcare. You would surely note this, that provider organizations were consolidating themselves. They were becoming more sophisticated. Hospitals were buying other hospitals. They were acquiring physician networks and other non-acute sites of care and becoming these integrated delivery systems. At the very outset of us forming Waystar, we sat with our management team and we said, "What does the market need?" And what we observed at that point in time, which still holds true today, was that as provider organizations were consolidating and becoming more and more sophisticated, there wasn't really an enterprise-caliber end-to-end software platform that could service the needs of these increasingly complex organizations.
And so we shaped our mission and our identity around that to simplify healthcare payments through using modern cloud software that would ultimately enable these providers who are busy and heroic people as they work to care for patients, like have them spend a lot less time worried about how they're going to get paid so they could focus more on patient care. So that's our mission, and I'm just so grateful to work alongside a group of people who care so much about our mission, and it really unites us in our purpose. The great thing about Waystar is that we do deploy software, and here's an instance of our cloud-based software platform. I'll tell you more about it as we go forward. But we're beginning to have scale, and we see the benefits of that scale.
Today, we serve over a million providers across every different care setting with the Waystar cloud-based software platform. So you can imagine that you can picture this in your mind in a setting where there might be five or 10 doctors practicing together, where they may not even have a dedicated IT person. They can rapidly get the benefits of deploying Waystar software, just like those that are practicing in very sophisticated, leading hospitals and health systems. We're grateful to work with 16 of the top 20 hospitals and health systems in the United States, where they have full IT departments, and they're constantly working with how they can optimize the use of the Waystar software platform. The great news here is that our software works in any variety of settings amongst any different types of providers. In total, we're reaching approximately 50% of the U.S. patient population each year.
And we're grateful and feel accountable to continuing to develop software that will meet the needs of those patients and the providers who serve them. We're going after a very large addressable market opportunity of about $15 billion a year, growing at approximately 5%. And our growth rate would indicate that we're growing faster, about two times the pace of the overall market. So we're gaining share as we process and meet the needs of these providers. We're processing over 5 billion insurance transactions annually within our software. And the processing of those transactions gives us tremendous insight into not only how to make our software and our network even more efficient as we connect providers with payers and also with patients, but it helps us then train and inform the algorithms that we use across our software to bring value to the providers that we serve.
You know, what I'd say here about the status quo in healthcare is we're amongst friends in saying that healthcare is an important part of our lives. It's certainly an important part of the United States economy. In the U.S., where we focus our solutions, we're spending over $4 trillion a year in healthcare. That's approximately 18%-20% of the U.S. GDP, and yet there's tremendous administrative waste within the healthcare system today, and I think about the lives of the providers that we serve. They wake up every day with a couple of things on their minds. One, they have a list of patients that they're going to go care for and see that day clinically, and then administratively, they're trying to figure out how they're going to account for that and to be able to appropriately get paid for the services that they're rendering.
It's a fact that providers bear the burden of understanding the hundreds of thousands of diagnostic codes associated with a clinical treatment with potentially millions of permutations. They have to stay up to date on all of those things as they account for the treating of a patient and as they seek insurance reimbursement. And there's a number of facts when you dig in here that you start to say, "Well, gosh, the status quo isn't sustainable." The majority of provider organizations are concerned and troubled by staffing shortages and the constant need to train new staff members on these diagnostic codes, which are constantly changing. We talk, and this is a flashpoint in the society that we live in today, that denied claims is a real thing. In a typical year, there's 450 million claims that get denied.
And while providers are trying to juggle with keeping up with all these diagnostic codes and they're leaving $50 billion a year of unbilled revenue on the table, part of the reason that they're not collecting is because there's 450 million claims that are getting denied, and the denial rates are not decreasing. They're increasing. And so it just compounds the issue, and it leads to a tremendous amount of administrative waste. I could go on and on here. The last thing I'd highlight is not only is there an impact to providers, there's also an impact to patients who they serve. Because when you think about, I don't know if you've had this experience, I had it recently with a member of my family who had a health service. We got a bill in the mail, and we didn't even understand what it was for.
Has that ever happened to anybody here? I hear some people laughing. The actual health service had occurred 70 days ago, and we were still waiting for insurance to kick in and adjudicate and figure out what insurance was going to cover and pay versus what Team Hawkins was financially responsible for, and that's an all-too-common situation where patients don't know, they're surprised, and we think there's a better way, and so this status quo, we're working to hit it head-on and disrupt the status quo with beautiful, easy-to-use, intuitive software. You can see a few examples of screenshots of our software we have built. Going back to what we initially intended to put together an architecture, we've built an enterprise-caliber software platform.
And as we talk about it, it's a software platform that's a workflow platform that closely matches the patient-provider and then the provider-payer exchanges that take place to bring clarity to, to bring simplicity to this journey that is affectionately referred to in healthcare as the revenue cycle. So we've created software modules, and you can see a list of example software modules below with the orange checkboxes. Everything from when a patient first interacts with a provider, typically a patient will be asked, "Do you have insurance?" and if you do, "Can you show us a proof of that insurance?" So we'll help the provider organization automate the insurance eligibility verification of that patient. We'll even help that provider organization in moments where a patient shows up at a hospital or a doctor's visit and they may not even know if they have access to insurance or not.
We process so many millions, billions of transactions using algorithms and AI. We can detect whether or not a patient has access. So we go through a coverage detection software service that we offer to the providers that we work with. And that, as you can see, as we move from one module to another, there tends to be a compounding benefit as the providers who we work with, who are our clients, they begin to use more and more of our software. This is a cloud-native solution. It's enterprise-caliber and built to endure and provide real value. It's cybersecure, and we compete on our ability to attest for modern cybersecurity protocols. And we're restless when it comes to thinking through all the different needs that we have to stay contemporary in a market where we're very aware about the risks of cybersecurity.
We work through a number of attestations, and we work to be very vigilant there. And what I'd also say is that within the software, there are prompts and there's training. There's in-app training that enables staff members working in these provider organizations to very quickly get caught up to speed and to be able to be efficient and effective users of our software. In sum, our software is delivering real and tangible return on investment. And at any point in time, there's well over 100,000 concurrent end users who are using our software the majority of their workdays to do real and lasting work. As I mentioned, AI is pervasive across our software platform, and we see all sorts of benefits that we're able to deliver to providers as they utilize our software.
Again, thinking through thematically, things such as reducing manual work through automation, reducing the likelihood of error because we're running algorithms and detecting when a diagnostic code may be missing from a claim that could rightfully be added to that claim to ensure a full reimbursement and an accurate reimbursement, and many other use cases. We're pleased just this morning to highlight that a new generative AI delivery within our software will be across our software platform. We call it Altitude AI. Its origins go back to how we formed Waystar as we worked to take our providers on a journey to their metaphorical summit.
We think that there's a lot of breakthrough opportunity in the use of GenAI to automate work, to prioritize work, to create and gather content behind the scenes so that individuals don't have to do that, and then to create more accuracy across the use of our software. So we're really pleased to just this morning announce Altitude AI as our generative AI platform. This has been in the works for quite some time. You've heard us, perhaps if you've listened to our earnings calls or read any of the transcripts there, that we last year announced a collaborative development effort with Google where we identified 12 generative AI use cases that we would begin working on that could really relieve some of the pain and burden that providers face.
And so just as we said we were going to do, we're pleased to launch this first one, and we expect that it will be well adopted as we're able to rapidly deploy this generative AI solution across the platform. Again, initially focused on the denial and appeal management process that historically has been very manual, Altitude AI, and within that, Altitude Create, will enable provider organizations to rapidly deploy GenAI to autonomously create appeal letters that will allow providers to very rapidly and accurately submit an appeal to a payer to secure timely payment from a claim that might have been initially denied. So we're really excited about that. Across the platform, we're producing powerful results that, and we go to market on a very tangible and demonstrable return on investment case. That's how we compete.
We talk about how our software lowers the cost of ownership, reduces manual work, accelerates time to payment, and brings more transparency, and so when you look at the different examples of what we're able to help providers who we serve achieve, we're excited. These tend to be motivators for us, so we're helping an otherwise understaffed and overworked organization find greater productivity, as you can see, 93% improvements in productivity. We're helping provider organizations who have historically waited several days with long AR balances to find faster time to payment and increased revenue as we help them engage with patients earlier in the patient journey to have conversations with patients about how they can participate in the financial side of their healthcare responsibility, and you can see we also deploy our software very rapidly, so there's a rapid time to value.
These are a few of the highlights that we use as we talk to providers and as they make decisions to procure software. We have strong win rates, and part of the reasons that we have strong win rates is because the value that providers achieve when they use our solutions is real and it's lasting, and so good software, real results, and we just feel so grateful to achieve some of these types of client satisfactions and industry recognitions, and we won't spend a lot of time here other than to say these moments of recognition kind of give us a sense that we're doing the right thing and we're building a bit of business momentum, and we're really grateful for that. I'm thrilled that Waystar is recognized on the list of Forbes' most trusted companies in the United States. That's not something to apply for.
That's something that they go out and measure, and trust means everything to us in the type of business that we're in. We're also a great place to work for our team members. We have fabulous team members. We have very strong Net Promoter Scores that we measure in every interaction that we can with clients who we feel grateful to work with. We're ranked in a number of different categories as a leading provider in the solutions in our space, and we'll stay very focused as we work to build a good company.
We also feel just so grateful to serve some of the finest institutions in the United States, and many of these participate with us. These are illustrative logos who you can read here on the screen, but many of them also participate with us in an advisory board setting where they're giving us great feedback and helping us ideate and further innovate. Conversely, we're helping them innovate, and we often hear from our clients, "You are helping us to reimagine what's possible in our desire to transform from the status quo within our organization. You're introducing software to us that can make a lasting difference." Part of Waystar's ability to serve over a million providers across all the different care settings is because of the fact that we integrate to over 500 different practice management, EHR, and hospital information systems. We've built those integrations over many years.
That creates an opportunity for us to serve providers in a variety of settings. And of those 500 integrations that we actively support, we have 200 active channel partner relationships where they're advocating for the use of Waystar software amidst the clients who use their practice management and electronic health record and HIS systems. So we're really grateful for that. Even in settings where a decision maker may choose not to insource the use of their technology but rather outsource it, we're grateful to work with some of the market-leading business process outsourcers. And again, our focus is software. We are not a tech-enabled services business trying to become more software-enabled. We're pure software, and so we're grateful to be able to partner with those that are also good solution providers when people do choose to outsource. Just a couple more thoughts here, then I'll pause for some Q&A.
We feel like we have conviction, and we have several proof points, deep proof points that give us excitement around our growth priorities. You can see highlighted here. First is we have an incredible installed base of clients. If we tell people that if we didn't add another software module or another client, we have a long runway to grow, long ways to grow within our client base. We could approximately double the size of our business by just focusing on our existing clients. Secondly, we're thrilled to be able to add new clients and to grow into this market. We tend to land relationships with clients, and then software module by software module, we're expanding those relationships with our clients over time.
Certainly, as we reach the market, to deepen our channel partner relationships is another important area of growth for us, and we have evidence of being able to do just that very consistently and just like we've announced this morning, the fourth growth pillar would be to continue to drive innovation that delights the clients who we work with and creates new market opportunities for us to serve them with software that helps resolve pain and gives them a real return on investment and then on the fifth bullet point, I would just simply add that we, in the forming of Waystar and over many years of now working together, part of our story has been that we've added nine acquisitions. Some have been tucked in nature, but all have been strategically valuable, value-creating, and important.
We believe that that fifth bullet point there to pursue strategic acquisitions, whether they be tucked in or more transformative in nature, that Waystar can play an important role in being a consolidator, just as we have done in the market to deliver value to provider organizations who we feel so grateful to serve. A few final bullet points, then I'll wrap it up, and I'll pause for Q&A with Annie, and I'll be grateful for that. Our comments are focused on the first three quarters of 2024. As you'll appreciate, we are in a quiet period, and we won't be talking about Q4 or any outlook for 2025 at this point in time, but we are pleased with the sustainable growth, the compounding nature of our business profile.
You can see nearly 20% revenue growth in the first nine months of 2024 with a focus and a disciplined orientation toward operational excellence, so this business, as we talk about a long-range target of Adjusted EBITDA margins around 40%, and sure enough, the Adjusted EBITDA margins in the first nine months, including our cost and transition to being a public company, is around 40.5%, and then, as we highlighted, we're delivering innovation on a very consistent basis, and we expect to continue to do just that. You'll hear us talk in our earnings call and in different moments where we do have the chance to comment in a public open period of time that we focus a lot on gross and net revenue retention. That gives us real conviction about our long-term growth opportunities.
You can see it's very consistent, 109% Net Revenue Retention for the most recent quarter in Q3 of public commentary, and we've averaged, though, over several quarters prior to that, anywhere between 108% and 110%. So it's just a consistent, durable double-digit growth path, and then we also call out growth in clients of scale, so you can see the KPI there is we continue to grow and enrich relationships and create enduring relationships where typically clients are using more and more of our software, and this metric on the right measures that, and we're pleased with the continued progress there. I'll highlight that you can see our revenue growth here. It's a highly visible and durable revenue growth, and then also our orientation toward profitability and efficiency. You've heard me talk about Adjusted EBITDA margins in the 40% target range.
Also, the business produces a tremendous amount of unlevered free cash flow, which we're pleased with. We used the proceeds of the IPO back in June of 2024, nearly $1 billion of proceeds to improve our balance sheet, to put us in a position where we could reduce our net leverage ratio. We've now done that down to it's a net leverage ratio of three times, and the business naturally delivers about a full turn a year. And so as we look to the future and we think about the strategic flexibility that this type of business model creates, we expect to, as we've talked historically, to be very disciplined in the use of our proceeds, but believe we can play an important role in the shaping of the U.S. healthcare system in the future. So with that, I'll pause and look forward to visiting with you, Annie.
Terrific. Thanks so much, Matt. That was an incredibly informative presentation. I feel like I have so many questions to ask, but the first one I want to start with is it's been a little bit under a year since you've been a public company, and I was just wondering maybe what some of your big takeaways over this time period have been both from the marketplace and just kind of the overall perception across your stakeholders. Sometimes what we hear from newly public companies is that it kind of helps their brand recognition. It kind of helps the pipeline a little bit because people know you, they understand you a little bit more, your financials are public, so they can trust you, as you talked about. You have really great trust, so just curious, how has being a public company impacted you over that time?
Yeah, well, thank you, so I would say a few thoughts. One is the opportunity to go public, I think, was a really special event for our team. It was one of those moments where we've long thought, let's behave as a public quality company. Everything we do, let's take a long-term view, building a business that can be the type of company that could go public, but to be able to actually finally go through the IPO was a really, it's a team sport, and it was a really validating experience for our team. I'd also highlight the fact that it has given us additional market awareness and recognition. There's a sense of validation that I think comes with revealing your financials and being willing to stand up to your financials and stand by them, and so we've noted that that's been good from a business activity perspective.
Think about this as well. In the same year that we went public, I think the U.S. market was grappling with the fact that there'd been a cyber attack on one of the major clearing houses in the space. You probably know which one I'm referring to. Change Healthcare was cyber attacked, unfortunately. And so because of that, I think that awareness that was generated as part of the IPO. We've been invited to an increasing number of opportunities to have our software be evaluated. And I think in Q3, we commented that we'd seen an uptick in the number of RFPs that we've been invited to and also have seen a strengthening of our opportunity pipeline through the course of the year. So I think that's been very validating for us.
That's great to hear. You sit in a unique area of the provider market in that you're really a mission-critical solution, and all of these providers have just been facing issues with labor shortages and trying to get paid because they've had such low margins. So can you speak to maybe the resiliency of demand for the revenue cycle solution space, the needs that you're addressing, and what's the status quo? What are you replacing?
Sure. I would say as we see the market, and we have a very focused and productive go-to-market team, but as we work to get into the minds of what's going on with these decision makers, we always think about how important is the revenue cycle solutions in the minds of decision makers, given its mission criticality, and every year we see it being ranked very highly on areas where they're focused on becoming more efficient. It's a fact that provider organizations, they expect increased utilization, and they have the same or less resources, and how do they grapple with that year in and year out, and so our solutions are oriented to create operating efficiency, to accelerate time to payment, and do those things. I think that's just kind of how we are focused as a business, and I think that it is a fragmented market.
We do find that we have the chance to, in this large addressable market of $15 billion and growing, that there's not really concentration of any one competitive vendor. There's a few vendors that we compete directly against, but it's also a fact that we're still replacing homegrown solutions or even things that are being done manually that could otherwise be done with our software today. So part of that market opportunity is our ability to create solutions like the one that we announced today, a generative AI solution, where historically following up on a denied claim with an appeal letter was really manual work. I see some people nodding their heads. That could be three, five, six hours of work of gathering content.
If we can replace that with something like Altitude Create and a generative AI solution that can gather content autonomously in less than a minute that's as accurate as a human and then be helpful to a provider, we see that there's opportunities to begin to have those conversations with clients and bring real value to them.
That was going to be one of my other questions is just around this kind of Altitude product. How receptive are your customers today to kind of leveraging AI? Because healthcare is always so slow, right? But everyone's very interested in AI, and it seems like it's really kind of a real problem solver. Administrative burden, it seems like such a natural place for AI to kind of help. NVIDIA spoke today about really splashy stuff with robots and all that kind of stuff, but it feels like this is really the nuts and bolts of where AI is going to be helpful for the healthcare system, and they might be willing to adopt it. So can you just maybe talk about that? Where is the next step, or what's the low-hanging fruit for you around AI?
Sure. We know statistically, we ran a survey last year with Modern Healthcare, and we know that the vast majority of decision makers and provider organizations are very interested in finding ways to begin to use AI and generative AI to address the operating efficiencies that they just have to obtain in their organizations. Something north of 90% are interested in beginning to use AI. I would share a couple of other facts with you. It's also a fact that these same decision makers are grappling with multiple point solutions. They're constantly trying to manage and integrate multiple point solutions of theirs. And even within the revenue cycle, sometimes they're using more than five, six, eight different solutions that are point solutions in nature and trying to figure out how to make them work.
What I think is exciting about Waystar is we've created almost with a lack of splash, if I can say it that way. We've taken an approach to generative AI where we've identified very specific use cases, given our subject matter expertise, where there's real pain associated with manual work, with the likelihood of error, with all sorts of things that just are difficult and create friction in the process of getting paid. We've created very focused use cases to ensure that as we apply generative AI to that, and then we deliver that technology in a cloud-based way that we can make available to hundreds of thousands of providers at one point in time.
We think that's the approach that we'll take, and I think that there will be an opportunity for us to learn a lot over the next several months and quarters about adoption and about what's working, but then in a very disciplined way, just continue to apply more and more GenAI solutions that we know that providers want. They're looking for a trusted partner that perhaps isn't a point solution. It's a platform approach where they can interact with them, and we think that Waystar can be that type of trusted partner.
That's great. I feel like we only have a little bit of time, but I feel like I would be remiss if I didn't ask you about you said something really interesting, I thought, in that in order to kind of hit your 10% growth algorithm, you don't need any incremental solutions. You can do it with what you have today. And I'm curious, you had this bolus of new customers that came on from the Change Healthcare cyber attack. So how should we be thinking about the contributions from new client growth, cross-sell, up-sell within that kind of long-term growth algorithm? And has that changed at all coming out of the Change Healthcare cyber attack?
Yeah. So what we provide and what we provided in Q3 was a little bit of a dialogue around what are the components of our revenue growth? And if you don't mind, I'll relay that for you just quickly. We start with a strong gross revenue retention rate of approximately 97%. And then as I highlighted a few moments ago, our net revenue retention is about 108-110. The most recent quarter was 109.4, to be exact. And that's not quite low double digits, but it's getting us close to that. And so the walk from gross to net revenue retention is a function typically of a modest annual price increase of 3% or so, some secular tailwinds associated with just regular patient visit increase and a natural increase in utilization of approximately 1-2% that our business model picks up and reflects.
And then the balance of that walk to 109% is cross-selling and up-selling our solutions. And so that type of consistent, durable 108%-110% net revenue retention rate gives us a sense of confidence that if we just focus on that and getting that right and being very disciplined there, then any new clients that we add to the platform will push us into that low double-digit revenue growth. And where we've had phenomenal growth in 2024, where we've been able to help so many providers who were affected by this cyber attack, we see that as a little bit above what our natural normalized revenue growth rate would be. And we've tried to highlight that in the various earnings calls that we've had. But we're certainly excited about the momentum that we've created in the business and believe that that will sustain with us as we go ahead.
Terrific. Well, we have 40 seconds left. What are you most excited for in 2025?
I think that in the face of the dialogue around the United States, there's a big discussion in our society about claims getting denied at an alarming rate. I think we just have this unique opportunity as builders of software, as we leverage artificial intelligence and GenAI to do good in society. If we can build software that helps providers spend more time with patients and bring clarity to their financial setting, and if we can bring clarity through that software to patients who then understand their financial responsibility, and we can dramatically reduce the likelihood that a claim gets denied and allow providers to rapidly follow up, then I think we're doing something good, and that's what gets me excited.
That's great. So much opportunity for improvement in the healthcare system.
Tremendous. Thank you.
Thank you so much for joining us today.
Thank you. Yeah. Thank you.