UnitedHealth Group engaged FTI Consulting to perform an independent assessment of policies, processes and controls related to our risk assessment operations. To do so, FTI had timely and unrestricted access to key documentation and personnel.
FTI observed that our approach to risk assessment generally involves robust documentation of our processes and observed evidence of key controls and routine oversight. FTI also identified potential opportunities for improved clarity in the organization and structure of our risk assessment policies and the procedural documents that support them.
UnitedHealth Group will ensure all policies and procedures are reviewed and approved at least annually and will maintain centralized policy repositories that are current, accessible, and consistently updated across all business segments. We are enhancing our enterprise-wide governance structures that outline roles and responsibilities for policy oversight, compliance monitoring, and risk assessment activities to ensure they are consistently applied and communicated effectively across UnitedHealthcare and Optum. We are also formalizing our governance for risk assessment and coding standards by implementing periodic reviews, defining approved coding credentials and establishing a second-line compliance audit function.
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.