Photo: Courtesy UnitedHealthcare
UnitedHealth Group has released the results of an external review of its business practices.
In July, independent consultancies FTI Consulting and the Analysis Group began a review that included UnitedHealth’s risk assessment operations within its Medicare Advantage business.
Reviewers looked at how the company managed patient care and, specifically, prior authorization requests by healthcare providers, according to Seeking Alpha.
FTI’s independent review focused on areas such as chart reviews, coding operations, quality assurance, data submissions, clinical support and compliance oversight, according to UnitedHealth Group.
Reviewers also looked at UnitedHealthcare’s policies, procedures and processes around care, including care quality review.
It also looked at Optum Rx’s policies and processes for ensuring prescription drug manufacturer discounts were accurately collected and distributed to clients. This is a regulatory issue facing government scrutiny due to rising drug prices in the U.S.
WHY THIS MATTERS
“In their reports, the assessors determined the company’s policies and practices are robust, rigorous and generally sound; and, in many respects, industry leading,” UnitedHealth Group CEO Stephen Hemsley said in a message to stakeholders. “The teams also identified several areas for improvement within each review and made recommendations to strengthen consistency and coordination.”
In response to the assessment, Hemsley said the company is taking 23 specific action plans in partnership with the respective businesses to track, validate and implement the recommended improvements in each area.
“The work is already well underway. Several action plans have already been completed,” Hemsley said. “Of the remaining actions, more than half will be finalized by the end of this year, and 100% will be finalized before the end of the first quarter next year.”
THE LARGER TREND
UnitedHealth Group will share the results of the review during the first quarter of 2026, according to Hemsley. This will include the results of a review of medical records and diagnosis codes identified during the company’s in-home HouseCalls visits. By mid-year the company will report on processes for evidence-based medical policy, he said.
Hemsley initiated the review after UnitedHealth disclosed in June that it was complying with both civil and criminal requests from the Department of Justice over its Medicare business.
In the letter to stakeholders, Hemsley said: “In June, shortly after stepping into the role as CEO, I committed to conducting a transparent and comprehensive examination of key processes and policies within our approaches to risk assessment, managed care practices and pharmacy benefits and services to validate what is working and, more importantly, identify areas for improvement. Today, I am pleased to share the independent assessors’ initial findings, which include a series of detailed recommendations for further strengthening and enhancing the protocols that govern our efforts.”
Email the writer: SMorse@himss.org