UnitedHealth releases 'independent review' of its medical policies
UnitedHealth Group has completed a year-long “independent review” of how well the company “develops and maintains its medical policies,” CEO Steve Hemsley revealed in a statement. The effort was initiated by the company in the wake of a major leadership shakeup and ongoing lawsuits from investors questioning the company’s business practices.
On Thursday, the report from FTI Consulting was released, though much of the analysis into UnitedHealth’s processes as it pertains to patient care claims reimbursement, denials and more, was conducted by Rubrum Advising—referred to as an “external physician-led medical coverage policy expert firm.”
Together, the two organizations said they performed a “[d]etailed review of UnitedHealthcare’s internal processes and controls for medical policy development and maintenance, with a comparison to external standards and guidance,” as well as an analysis of “selected medical policies developed by UnitedHealthcare.”
Notably, while the report is focused on policies related to medical coverage for members, the impact of patient care being denied was not part of the focus, something a group of investors attempted to pressure the company into looking into as part of this process—a move that ultimately failed.
“For policies within the scope of the review, the Review Team did not test or evaluate the specific content of UnitedHealthcare’s medical policies, how medical policies are applied in individual coverage decisions, or the completeness of the literature review UnitedHealthcare conducted in developing and maintaining its medical policies—such as search results, the literature relied upon, and UnitedHealthcare’s interpretation of the literature,” the review team wrote in its report.
A (mostly) glowing report
As a summary of the key findings, the groups wrote that UnitedHealthcare, the insurance arm of UnitedHealth Group, demonstrated a “strong and industry-leading approach to medical policy development, maintenance, and oversight.”
The consulting and advising firms said they looked into the actions of the company’s internal team responsible for medical policy and procedure development related to the approval and denial of medical claims, finding that their actions “reflected numerous best practices.”
“Medical policy development follows a rigorous, checklist-driven process grounded in systematic evidence review using industry best practices with clinical evidence sourced from nationally recognized authorities,” the report reads, offering some insight into internal oversight at the company:
“Epidemiologists actively support the clinical review process, providing critical support to medical policy medical directors, policy writers, and committee members; they assist with the evidence and study design evaluation at each step,” FTI and Rubrum concluded.
The medical policy team at UnitedHealthcare includes seven dedicated directors and more than 80 staff members, the report revealed.
The review looked at multiple types of health plans, including commercial coverage sold through the Affordable Care Act marketplace, as well as Medicare Advantage plans.
All policies are reviewed annually to ensure compliance with law and established best practices in the industry, according to the findings in the report.
There was some criticism included in the analysis, with Rubrum and FTI identifying areas for improvement. Mainly, the review team found some documentation was lacking, specifically pertaining to how UnitedHealthcare develops its medical policies related to care coverage.
The insurer could also do a better job of documenting the training it gives to its subject matter experts that shape policy at the company, the consultants found. Hemsley said he welcomed the criticism.
“The review also identified opportunities to make an already strong process even better, including more formally documenting certain practices and making our medical policies clearer, more consistent and easier to use,” the CEO of UnitedHealth Group wrote.
“We welcome these findings and will use them to continue strengthening our processes to better serve the people who count on us,” he added.
The full report is available here.
Chad is an award-winning writer and editor with over 15 years of experience working in media. He has a decade-long professional background in healthcare, working as a writer and in public relations.