MINNETONKA, MN — In a landmark move to restore public trust and navigate a complex regulatory landscape, UnitedHealth Group (UHG) has officially adopted 23 strategic action plans following an exhaustive independent audit of its internal operations. The announcement, made on Friday, December 19, 2025, signals a pivotal shift for the nation’s largest health insurer as it faces dual pressure from a Department of Justice (DOJ) investigation and rising patient backlash over its Medicare Advantage and Medicaid billing practices.
In a personal letter to investors and stakeholders, CEO Steve Hemsley framed the overhaul as more than just a regulatory necessity. “We hope that you see these assessments as a commitment to setting a new standard of transparency for the healthcare marketplace,” Hemsley wrote. “Every person who engages with our health system deserves to understand how we go about our work.”
The Audit: A Deep Dive into Medicare and Medicaid Integrity
The overhaul follows a rigorous review conducted by two prominent outside consultancies: FTI Consulting and The Analytics Group. While Hemsley noted that the consultancies found UHG’s existing policies to be “robust, rigorous, and generally sound,” the audit identified critical areas where the company’s implementation of those policies had faltered.
Key Audit Findings & Focus Areas:
- Medicare Advantage Risk Adjustment: FTI Consulting scrutinized how UnitedHealthcare manages risk assessments. A primary concern centered on the company’s HouseCalls program, which sends nurses to enrollees’ homes. Critics and federal regulators have previously alleged that such visits are used to “upcode” or identify lucrative chronic conditions to trigger higher government reimbursements.
- Optum Rx Discount Transparency: The Analytics Group reviewed how Optum Rx, UHG’s pharmacy benefit manager (PBM), handles manufacturer discounts. The audit highlighted a need for better automation in processing high-volume, low-complexity discounts and clearer reporting on exclusions.
- Corrective Action Implementation: The most striking find was that UnitedHealthcare had occasionally failed to fully implement corrective actions from previous regulatory audits, leading to “repeat violations.”
The 23 Action Plans: A Roadmap to March 2026
UnitedHealth Group has committed to completing 65% of its 23 action plans by the end of 2025, with full implementation scheduled for March 2026. These plans are designed to modernize the insurer’s infrastructure and ensure that audit recommendations are not just suggested, but enforced.
1. Enhanced Policy Governance
The company will now require all risk assessment and managed care policies to undergo a mandatory annual review and approval process. This includes a new “second-line” compliance review function to ensure that coding standards—the heart of the Medicare billing controversy—meet the highest ethical and clinical benchmarks.
2. Medicaid and Medicare Modernization
Major changes are coming to how UHG interacts with government-sponsored programs. For 2026, UnitedHealthcare Medicare Advantage will introduce stricter referral requirements for its HMO and POS plans. Additionally, new “Special Supplemental Benefits for the Chronically Ill” (SSBCI) will require verified chronic health conditions for members to access credits for healthy food and utilities, replacing older models that lacked stringent verification.
3. Automated PBM Efficiency
At Optum Rx, the company plans to streamline manufacturer discount administration. By automating high-volume processes, the firm aims to eliminate manual errors that have led to disputes with pharmacy providers and transparency concerns from corporate clients.
The DOJ Investigation: Why the Audit Matters Now
The timing of these changes is no coincidence. UnitedHealth Group is currently under the microscope of a U.S. Department of Justice antitrust and fraud probe. Investigators are examining whether the insurer systematically inflated Medicare diagnoses—a practice known as “upcoding”—to secure billions in overpayments from the federal government.
Recent studies published in Health Affairs in late 2025 indicated that UnitedHealthcare often pays its own Optum-owned practices up to 17% more than independent practices, a figure that jumps to 61% in markets where UHG has a dominant share. By proactively releasing audit results and adopting “action plans,” UHG is attempting to get ahead of potential DOJ indictments and clawbacks, which analysts at Morningstar suggest could reach into the billions.
The “Transparency Standard” or a PR Shield?
While CEO Steve Hemsley emphasizes a “new standard of transparency,” critics remain skeptical. The American Health Care Association and various patient advocacy groups have noted that UnitedHealth’s stock has declined nearly 34% in 2025, fueled by regulatory uncertainty and the fallout from the 2024 Change Healthcare ransomware attack.
The company is also grappling with the political fallout from the killing of its insurance division CEO, Brian Thompson, in December 2024. The tragic event sparked a national conversation about the frustrations patients feel with the American healthcare system, particularly regarding claim denials and high premiums.
Conclusion: A 10-Year Vision for Accountable Care
As UnitedHealth Group works toward its March 2026 deadline, the broader industry is watching closely. The move coincides with the Centers for Medicare & Medicaid Services (CMS) unveiling its new “LEAD” model—a 10-year push for accountable care that rewards health outcomes over transaction volume.
By overhauling its Medicaid and Medicare protocols and introducing independent oversight, UnitedHealth Group is betting that it can transform its image from a “black box” insurer into a transparent leader of value-based care. Whether these 23 action plans will satisfy the DOJ remains to be seen, but for millions of patients, the promise of a more “reliable and high-performing” UnitedHealth is a long-overdue development.