Two Thoreau-backed healthcare companies are partnering to bring real-time payer policy intelligence into revenue cycle workflows. The aim is to move claims denial management upstream into denial prevention, the companies said.
Revenue cycle management company Ensemble Health Partners will integrate Penelope Health's real-time policy intelligence into its platform. The aim is to make payer coverage rules visible and actionable before care is delivered, rather than discovering them after a claim is denied. Adding continuously updated policy intelligence to Ensemble's existing ecosystem means stronger decision support for health systems, Ensemble Health Partners executives said.
In June, Thoreau agreed to become the controlling shareholder of Ensemble Health Partners, a deal that reportedly valued the company at $12 billion.
Thoreau, a healthcare investment platform founded by private equity executive Matt Holt, says it is building healthcare’s foundational compute, rules and research infrastructure platform. Last month, Thoreau and other investors committed $100 million to Penelope Health, a company that turns fragmented health insurance rules into structured, real-time data, to support its effort to build a common infrastructure layer for healthcare payment and clinical rules.
The partnership with Ensemble Health Partners puts that technology into revenue cycle operations, pairing Penelope Health's view of published payer requirements with Ensemble's data on how insurers actually adjudicate claims.
The tie-up marks one of Thoreau's initial platform partnerships and signals the investment firm's broader infrastructure strategy to tackle administrative friction.
The partnership will combine Penelope's intelligence on published coverage rules with Ensemble's data on how those rules play out across real-world claims. Ensemble applies those constantly updated payer rules across authorization, denial prevention, billing and appeals. Penelope, in turn, will draw on Ensemble's operating scale and revenue cycle expertise to accelerate development of its platform for health systems nationwide, the companies said.
Ensemble, a 12-year-old company, manages end-to-end revenue cycle operations for health systems, including more than 200 hospitals, and more than $55 billion in net patient revenue. The company's platform spans RCM operations, including patient access, coding, claims management, denial prevention, accounts receivable follow-up and the patient financial experience. Ensemble's platform combines certified revenue cycle operators, data-rich intelligence and advanced artificial intelligence, according to the company.
Penelope's platform converts disparate sources of payer coverage rules and payment policies into a single structured reference, with access to policies covering more than 200 million Americans and spanning more than 15,000 procedure and drug codes.
"We're always looking for solutions and scanning the market for anything that advances our ability to reduce friction. Thoreau is a fantastic partner; their vision on reducing the administrative burden in healthcare aligns very well with Ensemble," Jim Gaffney, Ensemble's chief strategy officer, told Fierce Healthcare. "I would expect that other companies that they invest in are going to have similar visions, similar goals of what they're trying to accomplish. It's a natural fit because there's a great alignment between the vision for what we're trying to get done and the companies that Thoreau works with."
Payer clinical policies are scattered across different sources and formats, making them difficult for providers to find and interpret. As a result, providers may not identify requirements until after a claim is denied.
The partnership aims to turn constantly changing payer policies into actionable intelligence, helping Ensemble identify the impact of new rules and flag potential reimbursement issues before they lead to denials, Gaffney said.
"Penelope has built out a critical layer, a dependable, real-time view of clinical policy that will be additive to our proprietary end-to-end intelligence layer. Embedding that intelligence into the work our teams do every day means fewer denials, faster authorizations and stronger appeals for the health systems we serve, and more time returned to clinicians and patients," Judson Ivy, founder and CEO of Ensemble, said in a statement.
Ensemble aims to use payer policy intelligence upstream to prevent denials. That same policy intelligence can also strengthen appeals by allowing providers to cite specific payer rules when challenging a decision, Gaffney noted.
From Penelope Health's vantage point, Ensemble is a "natural partner" as it operates "at a scale, and with a depth of claims data and denial expertise," Sohum Patel, M.D., Penelope Health co-founder and CEO, said.
Mattijs De Paepe, Penelope Health co-founder and chief technology officer, said that "working alongside Ensemble’s platform and data teams lets us sharpen our build for the realities of the revenue cycle, by expanding the feedback loop between realized payer behavior and the rules codified in policies. This partnership accelerates our mission to turn the rules that govern coverage into infrastructure the whole system relies on."
Ensemble is also pushing deeper into AI for revenue cycle management. In March, the company unveiled a partnership with enterprise AI company Cohere to build an RCM-native large language model designed specifically for healthcare financial workflows.
The push for more clinical policy transparency also aligns with federal policy shifts. The Centers for Medicare & Medicaid Services (CMS) is implementing tighter rules to increase prior authorization transparency, accelerate decision timeframes and reduce administrative burdens for patients and providers.
"One of the largest problems that causes most friction is a lack of transparency of the rules that everyone's using to approve and pay for care," Gaffney said. "Some of that comes down to a lack of trust, and I think transparency increases that."
He added, "It's unclear how well each payer is going to comply with some of the regulations around transparency. Frankly, we're not in a position where we can wait for everyone to fully provide all the information. We have to be able to get ahead of it, and so Penelope is filling a gap there and can provide a broader view on the market. Being much more specific on the requirements in plain language, so that it can be clear whether those requirements are met or not met, removes a lot of friction and, frankly, a lot of frustration from some of these interactions."