UnitedHealth Group retained FTI Consulting to independently review UnitedHealthcare’s care services management processes, including care quality review. FTI reviewed 62 external regulatory audits related to care services management across UnitedHealthcare’s Medicare, Medicaid and commercial lines of business.
Both Medicaid and commercial plans are 100% compliant with the accredited standard-setting benchmarks. Care services management decisions are clinically grounded, evidence-based and regularly reviewed through industry-standard medical decision-making processes, with the medical policy department maintaining guidelines that exemplify best practices in the field. UnitedHealthcare’s care services management practices are frequently audited, with many recent audits having no negative findings. FTI identified improvements to consider, including formalizing a process for corrective action plans and reporting quality data to existing committees.
UnitedHealthcare is creating a comprehensive tracking and monitoring process for internal, external and regulatory audit findings. This process will include formal due dates, escalation protocols and reconciliation of external quality review reports to internal tracking to prevent repeat findings and ensure timely, complete action is taken to address any identified issues.
Care services management is a process used by health care companies to evaluate and manage medical services to ensure they are appropriate, necessary and cost effective. One important aspect of care services management is care quality review. Care quality review is not required for most types of care, but, when necessary, it is an important checkpoint that helps enable access to services that are safe, medically appropriate and supported by clinical guidelines, and minimize the chances that patients receive an unexpected medical bill.
Care services management processes like care quality review protect patients from out-of-pocket expenses and give care providers access to up-to-date care guidelines and advance coverage confirmation. At the same time, care quality review helps reduce waste by preventing unnecessary and low-value care.
UnitedHealth Group’s ongoing modernization initiatives are helping ensure care quality reviews can be made faster and less burdensome for care providers and patients alike. These initiatives include UnitedHealthcare’s Gold Card Program, which exempts provider groups with consistent adherence to evidence-based guidelines from care quality review for many procedures, as well as our significant steps to reduce the number of services requiring care quality review.