I’d rank Acentra’s investment bets by when each one returns cash.
I’d fund clinical review first, because it bills monthly while systems builds pay back over years.
Carlyle-owned since 2021;1 bought FEI Systems in Aug 2026.2
Systems builds score best on returns but wait 18 to 36 months for first cash.
Months from first spend to first cash, all my estimates.3
Line of businessEBITDAEBITDA. My estimate of the line’s margin once a contract is running, scored 1 to 3.1 to 3ROIROI. My estimate of how much a new dollar grows or protects revenue, scored 1 to 3. A fixed-scope federal contract scores low; a multi-year state system win scores high.1 to 30122436 monthsSpend to first cash
0122436 months
1
Clinical review and assessmentsUtilization managementUtilization management. Review of whether a requested service is medically necessary before or while a state pays for it., PASRRPASRR. Preadmission Screening and Resident Review, a federally required screen of people entering Medicaid-certified nursing homes for serious mental illness or intellectual disability.4 screeningFund first
EBITDAEBITDA. My estimate of the line’s margin once a contract is running, scored 1 to 3.2 of 3
ROIROI. My estimate of how much a new dollar grows or protects revenue, scored 1 to 3. A fixed-scope federal contract scores low; a multi-year state system win scores high.3 of 3
first cashcash
0122436 moFastest cash, high ROIEstimate: about 1 to 3 months
Sourced: Renewals in Colorado, five years (Aug 2026), and California, $27.5M over two years (2025).4
2
Medicaid systemsClaims and enterprise systems for statesFund in stages to go‑live
EBITDA3 of 3
ROI3 of 3
first cashcashspend before go‑livebuild
0122436 moLikely slowest, best returnsEstimate: about 18 to 36 months
Sourced: Idaho’s claims system pays out over $300M a month.5
3
Federal quality reviewMedicare quality improvement work for CMSProtect the margin
EBITDA2 of 3
ROI1 of 3
first cashcash
0122436 moSame timing, lower ROIEstimate: about 1 to 3 months
Sourced: $298M CMS renewal, 29 states, to Apr 2029.6
4
Long-term care and behavioral healthHome and community care technology, from FEIFund integration milestones
EBITDA1 of 3
ROI2 of 3
first cashcash
0122436 moLikely thinnest marginEstimate: about 6 to 18 months
Sourced: FEI adds 500+ people.2Estimate: margins least known.
This is a starting order, and Acentra’s own numbers by line would reset it in the first quarterly sprint.
How I’ve tackled a fixed investment budget
I ran product for a $30M AI startup inside Bayer and owned its P&L. Through quarterly planning sprints I directed $30M a year, ranking bets on EBITDA, cash flow and ROI and moving money and people from underperforming projects to stronger ones. Acentra’s four lines compete for dollars the same way.
The three pressures I’d check first all reach cash before they reach EBITDA.
State clients have less to spend at rebid. Nearly two-thirds of states rated a 2026 Medicaid shortfall 50-50 or likelier (Nov 2025).7To check: State versus federal revenue, and 2027 rebids.
Work requirements could add review work. States must start them by Jan 1, 2027 (CMS rule, Jun 2026).8To check: Which vendors states buy the checks from.
Systems contracts spend cash before go‑live. Idaho’s claims move to Acentra awaits a court ruling (Apr 2026).5To check: Spend before go‑live, and FEI integration targets.2
Each funded bet would reach the executive team with the outcome it moves and the cash it returns.
At Aidoc I built ROI models for COO and CFO buyers into business cases and renewals, and the foundation-model launch reached an eight-figure pipeline in year one. Each Acentra case would carry three things.
The outcome a state or CMS client sees
EBITDA and cash by quarter
The result that stops the funding, agreed up front
I’d test the order with two quarters of cash conversion on funded bets, against held‑back bets and the same quarters a year earlier.
Cash moves within a quarter; EBITDA follows a renewal later. Like quarters keep state fiscal-year timing out of the read. If held‑back bets improve as much, the market did it.