Utilization Management Process Review for UnitedHealthcare

This technical report presents the findings from FTI's review of UnitedHealthcare's utilization management processes. The review focused on three main areas: the processes and controls related to utilization management for medical services, the response to audit findings involving utilization management policies, and the maintenance of a clinical basis for the utilization management program. FTI conducted a thorough evaluation, which included reviewing relevant policies and procedures, analyzing reports from external audits, and engaging with stakeholders. The report highlights that utilization management is a critical component of healthcare delivery, ensuring that services are clinically appropriate and compliant with regulations. It outlines the major elements of utilization management, including evidence-based clinical policies, prior authorization, concurrent and retrospective reviews, and appeals processes. The report also discusses the results of 62 external audits conducted between July 1, 2023, and June 30, 2025, and provides key observations regarding UnitedHealthcare's compliance and areas for improvement in its utilization management practices.