UnitedHealth released a new audit of its insurance unit on Thursday, aiming to show how UnitedHealthcare builds clinical criteria for coverage decisions, a core element of CEO Stephen Hemsley’s transparency push.
Scope of the review
The assessment examined the expertise of an 80-person team that drafts medical policies, which dictate whether a treatment, drug or device qualifies for a member’s plan. It focused on the development process, not the day-to-day use of those policies.
Conducted by FTI Consulting and Rubrum Advising, the review sampled nine policies ranging from molecular testing for blood cancers to a surgery for children with scoliosis. Reviewers said the policies were evidence-based, well-researched and clearly defined.
However, the report noted gaps: there is no explicit trigger for creating a new policy, and the vetting of subject-matter experts lacks a formal checklist. The documents are also long and complex, which can hinder doctors and members.
“Overall, UnitedHealthcare demonstrates a strong and industry-leading approach to medical policy development, maintenance, and oversight,” the consultants wrote in their summary.
Denial patterns under scrutiny
Lawmakers and regulators have long questioned whether coverage refusals reflect profit motives rather than medical necessity. A recent KFF analysis found that UnitedHealthcare refused 17% of prior-authorization requests in Medicare Advantage plans, the highest among private insurers.
Sixty percent of those refusals were later overturned on appeal, suggesting many initial rejections may have been unwarranted. In Medicaid managed care, the initial refusal rate was 11%, yet more than 80% of those were reversed.
High-cost services showed the steepest gaps. In 2024, the HHS Office of the Inspector General reported that UnitedHealthcare denied over 70% of requests for long-term care hospital admissions.
The audit did not evaluate how the policies are applied in real-world decisions, nor did it assess any cost-saving considerations tied to refusals. This omission leaves a critical piece of the puzzle unaddressed.
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While the company declined to explain why application data were excluded, a spokesperson said the review was meant to answer whether UnitedHealthcare “develops, maintains and oversees its medical policies with rigor and in line with external standards and clinical evidence.”
Past audits, including one released in late 2025, found UnitedHealthcare’s request-handling processes compliant with external standards, but they did not measure approval or refusal frequencies across the insurer’s 48 million members.
UnitedHealth has been reshaping its corporate structure, cutting unpopular prior authorizations, and launching a series of audits to rebuild trust.
Hemsley said UnitedHealth will continue the audits and make changes “where needed,” signaling that further reviews are likely, though details on future scope remain pending.
Regulatory and legal scrutiny
Federal and state investigations continue to focus on the insurer’s handling of care requests. The Department of Justice has opened a probe, while two Democratic senators are investigating UnitedHealth over reports it restricted care for nursing home residents. In Texas, the attorney general has filed a complaint asserting unlawful denial of medically necessary care.
These inquiries intersect with earlier concerns about an alleged algorithm that systematically rejects treatments. The company has denied the existence of such a tool, emphasizing that policy decisions rely on clinical evidence rather than automated cost-cutting formulas.
In response, the insurer has pointed to its compliance with external standards in prior reviews of request-handling processes. Those earlier assessments concluded that the mechanisms for reviewing prior authorizations met regulatory expectations, though they did not measure overall approval frequencies.
Future audit directions
The next phase of transparency efforts may expand the scope to include real-world application of medical policies. Officials indicated that future reviews could examine how criteria are used at the point of care.
