Who we serve · Health plans
Payment integrity for commercial and Medicare Advantage health plans
AEGIS ISD gives health plan payment integrity and SIU teams one workspace to screen claims before payment, detect patterns after payment, investigate, run clinical and coding review, and track recoveries. One governed rule library covers both payment stages, and every decision is captured in an audit-ready record.
What gets in the way of payment integrity teams
- Two rule sets for two stages. Prepay edits live in one tool, postpay analytics in another, and the same logic gets maintained twice.
- Alerts that go nowhere. Alerts land in spreadsheets or email, and nobody can say which alerts became cases or recoveries.
- Medical records chased by hand. Record requests, reminders, and uploads are tracked outside the case.
- Workflow changes wait on the vendor. Every new queue, stage, or approval path is a professional-services ticket.
- Proving the compliance program works. Medicare Advantage plans must have measures that "prevent, detect, and correct" fraud, waste, and abuse as part of an effective compliance program (42 CFR 422.503(b)(4)(vi)), and auditors want the evidence trail, not a slide.
How AEGIS helps
| Need | AEGIS product | What it does |
|---|---|---|
| Stop bad claims before payment | Detect (prepay) | Screens pending claims against member claim history and reference data. Each rule recommends deny, suspend, review, or flag, and reviewers decide in a prepay review workspace. Finalized decisions are exported for handoff to your claims system. |
| Find patterns after payment | Detect (postpay) | Detection runs on paid and adjusted claims, risk-scored 0 to 100, with a dry run before alerts go live and an alert queue with evidence drill-down. |
| Coding and clinical edits | Detect base library | 100+ base rules across DRG, utilization, high dollar, unbundling, duplicates, coding abuse, and upcoding, backed by CMS NCCI PTP, MUE, and MS-DRG reference data. Tune, fork, or add your own. |
| Provider networks | Detect link analysis (add-on) | Shared-member concentration, referral concentration, and coordinated billing between provider pairs, with trial mode before alerts go live. |
| Investigate and recover | Case Management | Lead intake, configurable case stages and approvals, recovery tracking from pending to recovered, referrals and corrective actions, and dashboards and scheduled reports. |
| Clinical and coding review | Medical Review | Line-level decisions with reason codes, QA verification, appeals, and SVRS sampling with Mean Per Unit extrapolation. |
| Get records from providers | Provider Portal | Request letters by email or mail, one-time-passcode access with no provider account, virus-scanned uploads, automatic reminders, and a full activity trail. |
| Load your data | DataBridge | 837/835 feeds, flat files, JDBC, and APIs, with visual mappings, quality rules, and replayable runs. |
| Evidence and AI | Drive, AEGIS AI | Versioned case evidence, plus evidence-linked AI summaries under a five-level graduated trust model (Off, Shadow, Suggest, Confirm, Autonomous). |
The workflow, from claim to recovery
- Ingest claims, provider, and member data through DataBridge.
- Screen prepay. Detect recommends an action, and your reviewers release, suspend, or deny with a recorded reason. Detect does not deny claims on its own; the payment action stays with your claims system.
- Detect postpay. Detection runs score paid claims, and analysts triage the alerts.
- Investigate. An alert or prepay escalation becomes a Case Management lead in one step, with the evidence attached.
- Review. Medical Review handles clinical and coding decisions, Provider Portal collects the records, and SVRS sizes and draws samples when you need to extrapolate.
- Resolve and report. Record overpayments, recoveries, corrective actions, and referrals, and report alert-to-case conversion, cycle time, and recovery outcomes in Insights.
Built for Medicare Advantage and commercial lines of business
- Configure queues, SLAs, review stages, and approval paths per line of business, without custom code (Solutions).
- Read our guide: Prepay vs postpay FWA detection: where each rule belongs.
- Read our guide: SVRS for overpayment estimates: a practical guide.
Security and HIPAA
- SOC 2 Type II, ISO/IEC 27001, and CSA STAR Level 1, as listed on our Security page.
- AEGIS acts as a Business Associate and signs a BAA before any PHI is processed (HIPAA).
- Schema-per-tenant isolation, role-based access, TLS 1.2+ in transit, AES-256 at rest, and a timestamped audit trail.
- Visit the Trust Center.
Frequently asked questions
Does AEGIS replace our claims editing system?
No. Detect returns recommendations (deny, suspend, review, or flag) and your reviewers decide. Finalized prepay decisions are exported for handoff to your claims system, which keeps the payment action.
Can we use the same rule before and after payment?
Yes. Every rule has a payment stage of prepay, postpay, or both. Rules whose inputs exist before payment can move to prepay without being rewritten; rules that depend on paid amounts stay postpay.
Which edits are included?
More than 100 base rules across DRG, utilization, high dollar, unbundling, duplicates, coding abuse, and upcoding, backed by CMS NCCI procedure-to-procedure, MUE, and MS-DRG reference data. You can tune, fork, and add rules in Rules Studio and test them before go-live.
Can we start with one product?
Yes. Detect runs standalone for prepay review and alert operations, and Case Management runs without Detect or DataBridge. As you add products, they share administration, licensing, tenant isolation, and permissions.
How long does implementation take?
Most organizations launch their first program within 90 days: discovery (1-2 weeks), configuration (3-4 weeks), and training and launch (2-3 weeks).
Do you sign a BAA?
Yes. Our policy is to sign a BAA with each customer before processing PHI. A copy of the standard BAA is available from legal@aegisisd.com.
See prepay and postpay detection on your own scenarios.
Bring your current edits, pain points, and lines of business, and we'll tailor a 45 to 60 minute demo.