Fitch Ratings affirmed Team Health Holdings Inc.'s B- long term issuer default rating, with a negative outlook.

The ratings apply to $3.5 billion of debt as of Sept. 30, 2019.

Fitch said it expects Team Health's contract dispute with UnitedHealth Group Inc. to affect its financial cushion in 2020, leaving the company with less flexibility to deal with other negative developments such as legislation costs and federal regulations on balance or surprise billing.

The leverage of the Knoxville, Tenn.-based company was 8.5x at Sept. 30, 2019. This high leverage is due to a Blackstone sponsored leveraged buyout in early 2017 and the company's acquisitive posture, according to Fitch.

Team Health's low working capital and capital spending requirements, as well as expectations of no dividend payments in the near term, support the company's strong free cash flow.

Team Health provides outsourced healthcare professional staffing and administrative services to hospitals and other healthcare providers in the U.S.