SIU Case Management
Centralize evidence, communications, and determinations in one audit-ready case record for healthcare fraud investigations.
Healthcare Program Integrity Platform
Detect fraud. Investigate faster. Recover more.
AEGIS ISD is a unified healthcare program integrity platform that combines pre-pay claims intelligence, SIU case management, medical review, and recovery tracking in one audit-ready workspace. Built for Medicaid, Medicare, and commercial health plans.
Pre-pay fraud detection
Stop fraud before payment
Investigation cycle time
Faster case resolution
Audit-ready evidence
Immutable case timelines
Program Integrity Command Center
Pre-pay alerts
62
Medical reviews
28
Active investigations
57
Recoveries YTD
$2.4M
Weekly case completion rate
Case Investigation Timeline
Provider integrity case
- Claims analysis and authorization validated
- Medical necessity review completed
- Recovery recommendation and corrective action issued
What is AEGIS ISD
A healthcare fraud detection platform built for program integrity teams.
AEGIS ISD is a healthcare fraud detection and case management platform designed for Special Investigations Units (SIUs), program integrity departments, and medical review teams. Unlike legacy FWA platforms that require separate modules for detection, investigation, and recovery, AEGIS ISD unifies the entire fraud, waste, and abuse lifecycle in one configurable workspace.
Fraud Detection & Triage
Prioritize fraud alerts with configurable rules, risk scoring, and automated routing to the right investigator or queue.
Medical Review
Coordinate clinical peer reviews, medical necessity determinations, and documentation workflows with structured evidence.
Provider Surveillance
Monitor billing patterns, utilization outliers, and high-risk provider networks with continuous surveillance dashboards.
Recovery Tracking
Track overpayments, recovery actions, and corrective measures from identification through resolution.
Program Integrity Analytics
Measure alert quality, investigation cycle time, recovery outcomes, and investigator productivity in real time.
Pre-Pay Fraud Detection
Catch healthcare fraud before claims are paid.
Pre-pay fraud detection gives health plans a competitive advantage by identifying fraudulent, wasteful, and abusive claims before payment. Unlike post-pay recovery models that chase dollars already spent, AEGIS ISD's pre-pay intelligence stops improper payments at the source.
Higher First-Pass Payment Rates
Front-end validation of member eligibility, provider credentials, medical necessity, and prior authorization requirements reduces claim denials by catching errors and fraud indicators before adjudication.
Lower Administrative Costs
Automated pre-payment controls reduce manual review, rework, and downstream appeals. Health plans process higher claim volumes with greater accuracy and lower cost per claim.
Proactive Fraud Prevention
Early detection of unnecessary services, upcoding, unbundling, and provider fraud prevents improper payments before they enter the system. This protects plan margins and reduces the need for costly pay-and-chase recovery.
Stronger Provider Relationships
Faster, more predictable payments and fewer claim denials improve the provider experience. Health plans that deliver transparent, efficient reimbursement become preferred network partners.
How It Works
From suspicious signal to defensible outcome in four steps.
AEGIS ISD connects every phase of the healthcare fraud investigation lifecycle. Unlike legacy platforms that require manual handoffs between detection, investigation, and recovery, our unified workflow moves cases from signal to outcome with evidence captured at every step.
The investigation lifecycle
- Ingest — Normalize claims, provider, member, and external intelligence data into a unified case record
- Score — Apply configurable rules, risk models, and fraud indicators to prioritize high-value alerts
- Investigate — Manage evidence collection, clinical collaboration, peer review, and case determinations
- Resolve — Capture outcomes, overpayment recoveries, corrective actions, and regulatory referrals
AI-Powered Investigations
Ask questions in context. Get answers you can act on.
AEGIS AI Assistant is a context-aware AI built into every screen of the AEGIS ISD platform. While viewing a case, lead, document, or provider profile, investigators can ask natural-language questions and receive evidence-linked summaries, similar case matches, and recommended next actions. It is not a generic chatbot — it understands your active investigation context.
Summarize this case
Find similar providers
Explain risk signals
Recommend next steps
Extract document findings
AEGIS AI Assistant
Case Context
Question: What should we prioritize before closing this investigation?
Recommended actions
- Request missing clinical attachment from provider before determination
- Run similarity analysis against 3 recently resolved provider fraud cases
- Route to medical review queue — risk score exceeds clinical review threshold
Who We Serve
Built for the teams that protect healthcare programs.
AEGIS ISD serves program integrity teams across Medicaid, Medicare, and commercial health plans who investigate fraud, waste, and abuse.
Medicaid Managed Care Plans
Medicare Advantage Plans
Commercial Health Insurers
State Medicaid Agencies
Special Investigations Units
Program Integrity Departments
Security & Compliance
HIPAA-aligned security and CMS-ready audit controls.
AEGIS ISD is built for regulated healthcare environments. Every feature supports HIPAA compliance requirements, CMS program integrity guidance, and state Medicaid agency audit expectations.
Role-Based Access Control
Segment permissions by program, investigation type, and queue. Investigators see only the cases and data their role permits.
Immutable Audit Timelines
Every action, decision, evidence attachment, and communication is captured in an immutable, timestamped case timeline ready for regulatory review.
Tenant-Isolated Data
Each organization's data is isolated in a dedicated database schema. No shared tables, no cross-tenant data leakage, no commingled PHI.
FAQ
Common questions about AEGIS ISD.
What is AEGIS ISD?
AEGIS ISD is a healthcare program integrity platform that unifies fraud detection, SIU case management, medical review, and recovery tracking in one workspace. It is designed for Medicaid, Medicare, and commercial health plan program integrity teams who investigate fraud, waste, and abuse.
Who uses AEGIS ISD?
AEGIS ISD is used by Special Investigations Units (SIUs), program integrity departments, medical review teams, and compliance officers at health plans and state Medicaid agencies.
How is AEGIS ISD different from legacy FWA platforms?
Unlike legacy platforms from vendors like Cotiviti, Optum, or SAS that require separate modules for detection, case management, and analytics, AEGIS ISD provides a unified workspace where all investigation activities happen in one place. It also includes a 5-level graduated AI trust model, schema-per-tenant data isolation, and no-code workflow configuration.
How does AEGIS ISD support pre-pay fraud detection?
AEGIS ISD brings intelligence and detection upstream into the pre-pay claims process. By validating eligibility, authorization, and medical necessity before payment, it reduces improper payments, claim denials, and the need for costly post-pay recovery.
Can workflows be configured for different programs?
Yes. Queues, SLAs, review stages, evidence requirements, risk scoring rules, and approval paths are fully configurable by line of business — Medicaid, Medicare, or commercial — without custom code.
How does AEGIS ISD support audit readiness?
Every case decision, evidence attachment, communication, and status change is captured in an immutable timeline. Cases can be exported with full audit trails for CMS, state MFCU, or internal compliance review.
Get Started
Ready to modernize your healthcare fraud detection?
Schedule a demo tailored to your program integrity workflows, data sources, and investigation requirements.
What to expect in a demo
- Program discovery and workflow mapping session
- Integration planning for claims, provider, and member data
- Live walkthrough of case management, detection, and AI assistant
- Discussion of implementation timeline and phased rollout