UnitedHealth Group has released findings from multiple independent reviews of its business practices following a June pledge from CEO Stephen Hemsley to conduct a transparent and comprehensive examination of company processes.
The reviews, conducted by FTI Consulting and Analysis Group, examined Medicare Advantage risk adjustment operations, utilization management practices, and Optum Rx’s administration of manufacturer discounts. UnitedHealth has adopted 23 action plans in response, with 65% targeted for completion by year-end and full implementation by March 31, 2026.
Ten things to know:
1. Across all three areas, the auditors concluded that UnitedHealth maintains strong operational controls and documentation. However, a common theme emerged: policy organization, centralization and governance structures need improvement. The risk adjustment review found policies weren’t always codified or recently reviewed; the UM review found corrective actions that weren’t fully remediated; and the PBM review recommended consolidating and streamlining policy documentation.
2. In response to the findings, UnitedHealth said it will ensure all policies and procedures are reviewed and approved at least annually, maintain centralized policy repositories, and enhance enterprise-wide governance structures outlining roles and responsibilities for policy oversight, compliance monitoring and risk assessment activities.
3. FTI reviewed Optum’s risk adjustment diagnostic coding standards against ICD-10-CM guidelines and found the content consistent with official coding guidance. The HouseCalls in-home assessment program received strong scores, with “comprehensive and well-organized” policies and evidence that the majority had been reviewed within the past 12 months.
4. FTI recommended separating coding audit functions from operations. Currently, targeted coding audits directed by Optum compliance are performed by coding resources that report into coding operations rather than compliance. FTI recommended establishing dedicated coding audit resources within compliance itself. UnitedHealth’s action plan confirms it will “establish an independent coding audit team within the broader Optum compliance organization.”
5. UnitedHealthcare holds national NCQA utilization management accreditation with 100% scores. The insurer achieved the accreditation in 2023, which deems its Medicaid and commercial plans 100% compliant with NCQA utilization management standards. When benchmarked against Medicaid peers in external quality reviews, UnitedHealthcare met full compliance in all 12 states examined, scoring 100% on prior authorization and practice guideline standards.
6. Nine of 62 UM audits showed corrective actions that weren’t fully remediated. While 42% of the UM-related audits FTI reviewed had no negative findings, auditors flagged instances where corrective actions from previous audits remained unresolved. FTI found UnitedHealthcare lacks “an overarching control” to ensure full remediation of all audit findings and recommended formalizing a standardized tracking mechanism with dashboards and internal thresholds independent of regulator deadlines.
7. The UM review questioned how quality management is operationalized. FTI observed that while multiple teams have roles in quality improvement for utilization management, “there did not appear to be a documented, centralized process or cross-functional accountabilities” to oversee systemic improvement opportunities. The quality management team’s UM role focuses on maintaining NCQA accreditation rather than leading broader quality improvement activities, FTI found.
8. Analysis Group identified 25 distinct controls in Optum Rx’s manufacturer discount administration. The PBM review concluded that Optum Rx has “built a robust and well-structured governance framework” for collecting discounts from drug manufacturers and disbursing them to clients.
9. Optum Rx was advised to improve client reporting on why certain claims don’t generate rebates. While the PBM provides information on claims deemed ineligible for manufacturer discounts upon client request, Analysis Group recommended assessing opportunities to enhance this reporting proactively. The firm also suggested refining escalation processes for manufacturer disputes and non-payment, and evaluating automation opportunities for low-complexity, high-volume processes.
10. All three reviews had limitations. The auditors did not test the effectiveness of controls, did not perform legal analysis, and expressly disclaimed any opinion on legal compliance. FTI’s UM and risk adjustment reviews focused only on current-state policies, not historical practices. Analysis Group noted its PBM review “did not identify deficiencies” but rather “opportunities to further enhance efficiency and oversight.”
