UnitedHealthcare’s medical policy development process is “strong” overall and was described as “industry-leading” in a newly released external review of the insurer’s internal procedures that influence coverage decisions.
The UnitedHealth-commissioned report was conducted by FTI Consulting and Rubrum Advising, a physician-led medical coverage policy firm. It examined the company’s processes and controls for writing and maintaining policies, the qualifications of the staff involved, committee oversight and approval structures, and a sample of nine individual policies.
Notably, the review did not look at how UnitedHealthcare’s medical policies are applied in actual coverage decisions, the specific content of the policies, or cost considerations associated with those decisions. It also excluded drug and behavioral health policies.
The nine sample policies reviewed spanned a range of clinical evidence levels, from emerging areas like vertebral body tethering and molecular oncology testing to well-established topics like breast cancer imaging and durable medical equipment. All nine met the review criteria and were found to be evidence-based and well-researched.
The insurer’s medical policy team is made up of more than 80 people that includes physicians, nurses, epidemiologists, certified coders and communication specialists. Seven full-time medical directors oversee policy development, and policy writers go through 18 months of mentorship and training with an epidemiologist. The reviewers also called the medical policy team’s use of internal appeals data to evaluate and refine policies a “unique, high-quality practice.”
Despite the overall high marks, the reviewers noted that UnitedHealthcare’s policies are “dense and complex,” making daily use by providers and members difficult. The company also lacks explicit documentation for when and why a new policy should be developed, and the process for vetting subject matter experts who weigh in on policy development is not formally documented.
The medical policy review is the latest in a series of independent audits that UnitedHealth CEO Stephen Hemsley committed to after coming back to lead the company in 2025, following a period of financial turmoil and the killing of UnitedHealthcare CEO Brian Thompson in late 2024.
In a Nov. 12 statement, Mr. Hemsley said UnitedHealth “welcome[s] these findings and will use them to continue strengthening our processes to better serve the people who count on us.”
The insurer has faced intensifying scrutiny over its coverage practices from federal lawmakers over the last few years, including allegations it incentivized nursing homes to avert medically necessary hospital transfers for their residents, and that it used AI and prior authorization to incorrectly deny post-acute care to Medicare Advantage members.
