Who we serve · State Medicaid & government
Program integrity software for state Medicaid agencies and government investigators
AEGIS ISD supports state Medicaid program integrity units, Medicaid Fraud Control Units, and program integrity contractors with one workspace for detection, preliminary and full investigations, medical review, statistically valid sampling, and recovery tracking. Every step is recorded for audit, referral, and federal reporting.
Pain points in government program integrity
- Investigations that must hold up. State Medicaid agencies must have methods for identifying suspected fraud, conduct preliminary and full investigations, and refer suspected fraud to the MFCU (42 CFR 455.13 to 455.17). The case file has to show what was done, when, and why.
- Payment suspensions with deadlines. A payment suspension based on a credible allegation of fraud brings notice, referral, periodic certification, and documentation-retention duties under 42 CFR 455.23.
- Managed care oversight. Medicaid MCOs, PIHPs, and PAHPs must report overpayments and refer potential fraud to the state (42 CFR 438.608), so the state gets referrals from many plans in many formats.
- Extrapolation challenges. Projected overpayments get challenged on method, so sampling parameters, seeds, and work papers need to be reproducible.
- Legacy systems and data warehouses. Claims sit in the MMIS or a data warehouse, and every new report needs a vendor change request.
How AEGIS helps
| Need | AEGIS product | What it does |
|---|---|---|
| Surface suspect providers and claims | Detect | Postpay detection runs risk-score paid claims 0 to 100. Includes provider and member profiles with peer percentiles, CMS NCCI and MUE reference data for Medicare and Medicaid practitioner, outpatient hospital, and DME services, and a dry run before alerts reach the queue. |
| Network schemes | Detect link analysis (add-on) | Shared-member concentration, referral concentration, and coordinated billing between provider pairs, with watch lists and trial mode. |
| Preliminary and full investigations | Case Management | Lead intake from referrals, hotlines, or Detect alerts, with duplicate checks. Configurable stages, substages, tasks, and approvals; jurisdiction scoping; and referrals, corrective actions, and law-enforcement outcomes on the case. |
| Clinical and coding review | Medical Review | Clinical, coding, and QA reviewers, line-level decisions with reason codes, and appeals and re-reviews. |
| Defensible sampling | SVRS | Cochran's-formula sample sizing with finite population correction, seeded Fisher-Yates selection, and Mean Per Unit extrapolation. Supports probe, nested, and member-universe samples with a one-sided 90% lower bound, and saves methodology and extrapolation PDFs to the case. Aligned with HHS-OIG RAT-STATS conventions. |
| Records from providers | Provider Portal | Request letters by email or mail, passcode access without a provider account, virus-scanned uploads, reminders and notices, and an activity trail with CSV export. |
| State data | DataBridge | 837/835, flat files, JDBC, and REST sources, with mappings, quality rules, lineage, and replay without re-ingest. Integrations listed on Platform include OIG exclusion lists, SAM databases, and state Medicaid data warehouses. |
| Evidence for counsel and regulators | Drive | Versioned case evidence and time-bound shared links for outside counsel or regulators. |
| Program reporting | Insights | Alert-to-case conversion, cycle time, recovery, and executive dashboards, plus scheduled reports in XLSX, CSV, PDF, or HTML. |
Workflow mapped to the Medicaid investigation lifecycle
| Step | Where it lives in AEGIS | Reference |
|---|---|---|
| Identify suspected fraud (data analysis, complaints, referrals) | Detect alerts and Case Management lead intake | 42 CFR 455.13 |
| Preliminary investigation | Case stage with tasks and approvals | 42 CFR 455.14 |
| Full investigation and MFCU referral | Case stage, with referral and outcome tracking | 42 CFR 455.15 |
| Resolution (no action, education, recovery, sanction) | Case resolution, corrective actions, recovery tracking | 42 CFR 455.16 |
| Overpayment projection | SVRS + Medical Review | HHS-OIG RAT-STATS conventions |
The table shows how AEGIS workflows can be configured for each step. It is not a certification or federal approval of AEGIS.
For MFCUs and program integrity teams
- MFCUs operate in all 50 states, DC, Puerto Rico, and the U.S. Virgin Islands. Most sit in the state Attorney General's office, separate from the Medicaid agency, and are recertified by HHS-OIG every year (HHS-OIG MFCU page).
- AEGIS's CEO, William Stewart, was Deputy Chief of Staff to the Florida Attorney General, where he oversaw the Medicaid Fraud Control Unit (About).
- CTO Muruganantham Mani architected the modernization of the CMS Unified Case Management system used by Medicare and Medicaid program integrity contractors (About).
Security and HIPAA
- SOC 2 Type II, ISO/IEC 27001, and CSA STAR Level 1, as listed on our Security page, with a CSA STAR registry entry.
- BAA signed before any PHI is processed (HIPAA), plus schema-per-tenant isolation, SSO/SAML and MFA, and a full audit trail.
Procurement details
- UEI (SAM.gov): YNNSLKUGVQM4
- CAGE code: 1ZW79
- NAICS codes: 541511 (primary), 541512, 541519
Frequently asked questions
Can AEGIS apply Medicaid NCCI edits?
Yes. Detect includes CMS NCCI procedure-to-procedure and MUE reference data for both Medicare and Medicaid (practitioner, outpatient hospital, and DME). CMS notes that Medicaid NCCI differs from Medicare NCCI, for example in DME edits and in applying MUEs per claim line.
Is SVRS the same as RAT-STATS?
No. RAT-STATS is free statistical software from HHS-OIG. AEGIS SVRS runs inside the case workflow and follows RAT-STATS conventions for parameters, random-seed disclosure, sample-size derivation, and Mean Per Unit output, so its documentation is familiar to auditors who use RAT-STATS.
Can an MFCU use AEGIS for data mining?
MFCU data mining is governed by HHS-OIG rules; see OIG's policy transmittal on permissible data mining activities on the HHS-OIG MFCU page. AEGIS provides the tooling. Each unit decides what its approvals allow.
Can we receive referrals from our managed care plans?
Yes. Leads can be entered manually or by referral. Duplicate checks flag leads that match an existing case.
Do you support migration from a legacy case system?
Yes. Migration support for existing cases is offered during onboarding.
Talk with people who have run program integrity from the inside.
Tell us about your program, data sources, and reporting obligations, and we'll tailor the demo.