Who we serve · Special investigations units
SIU case management software for healthcare fraud investigations
AEGIS ISD gives healthcare SIU investigators and supervisors one case record from first lead to final recovery. That covers intake and triage, configurable investigation stages, medical records requests, clinical review, statistically valid sampling, referrals, and recovery tracking, with AI assistance your team controls and a full audit trail.
What slows SIU teams down
- Leads from everywhere. Hotline calls, internal referrals, analytics alerts, and regulator tips arrive in different formats, and some are duplicates of open cases.
- Five tools for one case. Notes in one system, records in email, claims in spreadsheets, and recoveries in finance.
- Chasing medical records. Letters, reminders, second notices, and uploads are tracked by hand.
- Supervisors without a view. Workload, aging, and outcomes get rebuilt in a spreadsheet every month.
- Defending the result. Extrapolations, referrals, and settlements need a reproducible record.
- Regulatory reporting. MA plans must make a timely, reasonable inquiry into potential FWA and take corrective action (42 CFR 422.503(b)(4)(vi)(G)). Medicaid managed care plans must promptly refer potential fraud to the state and report overpayments (42 CFR 438.608).
How AEGIS helps
| SIU job | AEGIS product | What it does |
|---|---|---|
| Intake and triage | Case Management | Leads by manual entry, referral, or Detect alert, with bulk assign, duplicate checks, and configurable priority scoring by lead source, allegation type, and dollars at risk. |
| Work the case | Case Management | Configurable stages, substages, tasks, and approvals; allegations with CPT codes; claims import with de-duplication; an entity index by NPI or member ID; and My Workboard, Team Board, and Global Queue. |
| Get the records | Provider Portal | Request by email (up to 10 recipients) or printed letter. Providers verify with a six-digit email passcode and need no account. Uploads up to 500 MB per file are virus-scanned, with automatic reminders and first and second notices. |
| Clinical and coding review | Medical Review | Assign clinical, coding, and QA reviewers; record line-level decisions with reason codes; send cases back to the case team; and handle appeals and re-reviews. |
| Sampling and extrapolation | SVRS | Seeded, reproducible samples and Mean Per Unit extrapolation, with methodology PDFs saved to the case. |
| Evidence | Drive | Folders, full version history, and time-bound shared links for outside counsel or regulators. Included with Case Management. |
| AI assistance | AEGIS AI | Case summaries and recommended next steps linked to the evidence behind them. Five trust levels from Off to Autonomous, with Confirm recommended for most production use, and prompt context, model version, output, and reviewer decision all logged. |
| Recover and report | Case Management + Insights | Billed, paid, suspect, overpayment, and recovered amounts; referrals, corrective actions, and law-enforcement outcomes; and about 50 dashboard widgets and scheduled reports. |
| Leads from data | Detect | Prepay and postpay alerts hand off to a Case Management lead in one step, with evidence attached. |
An SIU case in AEGIS
- Lead arrives from a hotline, referral, or Detect alert. It is checked for duplicates, scored, and assigned.
- Preliminary review. Pull claims into the case, look up the provider in the entity index, and check prior cases.
- Records. Send a Provider Portal request. Reminders run automatically, and staff validate the upload.
- Review. Medical Review records line-level findings, and SVRS samples and extrapolates if needed.
- Determination. Approvals, provider education or corrective action, overpayment, and referral to law enforcement or the regulator.
- Recovery and close. Track amounts through to recovered. The case keeps a complete audit trail.
For supervisors and SIU directors
- Team Board and Global Queue for workload balance and aging.
- 12 system roles and jurisdiction scoping, so investigators see only what they should.
- Lead Performance Dashboard in Insights and executive workspace in Case Management.
- No-code changes to stages, queues, and approval paths (Platform).
- Built by investigators: CEO William Stewart has more than 20 years in FWA, including overseeing the Florida Medicaid Fraud Control Unit as Deputy Chief of Staff to the Florida Attorney General (About).
Security and HIPAA
- SOC 2 Type II, ISO/IEC 27001, and CSA STAR Level 1, as listed on our Security page.
- BAA before PHI (HIPAA), schema-per-tenant isolation, role-based access, masked member IDs in Detect profiles, and a complete audit trail.
- Trust Center and system status.
Frequently asked questions
Can we run Case Management without Detect?
Yes. Case Management runs standalone. Leads can be entered manually or by referral, and Detect can be added later.
Do providers need an account to upload records?
No. Providers open the request with a reference number and access code, then verify with a six-digit passcode sent by email.
How does AEGIS AI handle investigator decisions?
AEGIS AI is decision support. You set the trust level per capability, from Off through Shadow, Suggest, and Confirm to Autonomous. Confirm, where a person approves every action, is recommended for most production deployments, and every AI interaction is logged.
Can we share evidence with outside counsel?
Yes. Drive can create time-bound shared links for outside counsel or regulators, and every file keeps a full version history.
Can we move our open cases from our current system?
Yes. Migration support for existing cases is offered during onboarding.
See a case go from lead to recovery in one record.
Bring a typical case, and we'll walk it through AEGIS in a 45 to 60 minute demo.