In December 2025, UnitedHealth Group published the findings of an independent review by FTI Consulting of policies, processes, and controls related to risk assessment operations. FTI found that the company’s approach generally involved robust documentation, key controls, and routine oversight, while also identifying opportunities to improve clarity, governance, and supporting documentation.
UnitedHealth Group has now implemented all improvements announced in response to the initial review released in December. Those improvements strengthened policy governance, documentation standards, coding oversight, compliance review, and risk assessment controls across the business.
FTI Consulting also conducted an independent review of HouseCalls coding practices to assess whether diagnosis codes submitted to and accepted by CMS were supported by the medical record. Based on a random sample of 200 HouseCalls visits from 2025, representing 494 Member-HCCs, the review found 99 percent of sampled diagnoses were supported by medical records or reflected in paid claims.
In its first-pass review, FTI found that the medical records supported 96.6% of sampled Member-HCCs. The resulting 3.4% rate of unvalidated diagnoses is nearly three times lower than the error rate CMS reported for its most recent industry audit of Medicare Advantage medical record reviews and lower than the 5% coding-variation threshold CMS uses in RADV-related audits.
After receiving FTI’s initial findings, our company reviewed the 17 diagnoses FTI could not initially validate based solely on the HouseCalls record and found support for most in the patient’s care history, including paid claims.
In a second-pass review, FTI found confirmation for 12 of the 17 diagnoses after reviewing medical records and paid claims.
Taken together, these results validate the integrity of the HouseCalls program, but we will continue to strive to ensure that only appropriately supported diagnoses are submitted to CMS.
While these are meaningful results, we are committed to doing better.
We established a Care Connectors team that manages follow up needs. When a clinician identifies a new or worsening condition during a home visit, they connect the person to a Care Connector before leaving the home to schedule follow up care, help find providers, answer questions and link to community resources. Care Connectors remain engaged after the visit to track follow up and ensure members get the care they need without navigating the system alone.
Risk assessment ensures health plans receive appropriate funding based on the health status of their enrolled members. Plans caring for sicker patients with more complex needs receive higher payments; those with healthier populations receive less.
Without risk assessment, health plans would have strong financial incentives to avoid enrolling sicker patients and offer plans only to healthier people – undermining the fundamental purpose of Medicare. Risk assessment helps level the playing field so all who are eligible, regardless of their health status, have access to affordable, high-quality care.
Independent CMS audits routinely confirm that UnitedHealth Group’s risk assessment practices are among the most accurate in the industry, and we are proud of our record of responsible conduct and compliance. Risk assessment is an important component of our broader commitment to accelerate the health care system’s transition from fee-for-service to a value-based approach that prioritizes patient health by incentivizing disease prevention, early detection and comprehensive care coordination.