By Cris Deacon
Trying to audit your own claims with UnitedHealth Group‘s UMR? Brace yourself.
What should be a basic fiduciary right is treated like a privilege you have to beg (and pay) for. UMR’s demands and requirements don’t empower clients—it attempts to fence them out, then wraps them in red tape and charges admission.
The image shared here is language taken from an email a UMR representative sent to a large consultant, laying out the terms for a client attempting to use a claims review vendor.
Here’s what these terms mean:
▪️ $75,000 annual fee just to get in the door. That’s before a single claim is shared or reviewed—this is the cost for an employer before a single claim is reviewed.
▪️ The client is forced to enroll in UMR’s Payment Integrity (PI) program. If the client does not want to enroll (and pay for) UMR’s PI program, they aren’t allowed to engage another third party to perform these services. Never mind the fact that the reason the client needs a third party is because UMR’s PI program is clearly not satisfactory to the client.
▪️ The client’s vendor will only get data after 120 days, so by the time they see claims, they have been run through UMR’s PI program and they are probably already stale.
▪️ And even after 120 days, there are some data fields that they will NOT release – including pricing methods, coding supplements, and line level data.
▪️ While UMR says that the “Raw claims” (including billed amounts) are technically client-owned, anything post-adjudication is considered UMR’s property, requiring NDAs, vetting, and contract amendments. And what good is “owning” raw data if you can’t see how claims were actually priced, adjusted, or paid—especially when you only get it 120 days later?
▪️ Oh, and your reviewer is barred from speaking directly with providers. That means no verifying billed charges, no clarifying coding, no reconciling discrepancies—making it impossible to validate the claim at its source.
Bottom line: if a client suspects UMR’s adjudication or claims handling isn’t measuring up, the path to independent review is paved with fees, delays, legal guardrails, and missing data. Transparency here isn’t a right—it’s a privilege you have to pay for. And even then it comes with a price tag, delays, and restrictions that strip it of real value.
Later this week, I’ll highlight HCSC’s unreasonable demands on employers who’ve successfully used third-party claim reviewers.
Spoiler: the same theme applies—pay up, shut up, or give up.
