UnitedHealthcare Utilization Management Review

This technical report presents the findings of FTI's review of UnitedHealthcare's utilization management processes. The review focuses on three main areas: the processes and controls related to utilization management for medical services, the response to key findings from audits concerning utilization management policies, and the maintenance of a clinical basis for the utilization management program. FTI conducted a comprehensive evaluation that included reviewing related policies, procedures, and documentation, as well as holding discussions with stakeholders. The report outlines the regulatory environment surrounding utilization management, highlighting its importance in ensuring appropriate healthcare services. It also details the results of 62 external audits conducted between July 2023 and June 2025, noting that many audits found no negative findings. The report concludes with observations regarding the strengths of UnitedHealthcare's program and areas for potential improvement, particularly in the corrective action process for audit findings.