UnitedHealth Audit Skips How Medical Policies Drive Denials
UnitedHealth released results Thursday from an audit by FTI Consulting and Rubrum Advising examining how UnitedHealthcare develops and maintains the clinical criteria used in coverage decisions. The review found the policy-development process well-staffed and evidence-based, with only minor gaps such as unclear documentation standards and overly complex policy language, but it did not assess how those criteria are actually applied to individual coverage decisions or whether cost considerations factor into denials. UnitedHealthcare covers more than 48 million people. Separately, the article cites a federal watchdog finding that in 2024 UnitedHealthcare had one of the highest denial rates among Medicare Advantage insurers for long-term care hospital admissions, rejecting over 70% of such requests, with skilled nursing denials overturned 99.7% of the time on appeal; a KFF analysis also found UnitedHealthcare's Medicaid managed care prior authorization denial rate was 11%, with over 80% of those denials overturned on appeal.