A La Carte Auditing for Commercial Plans

Aegis helps commercial payors protect premium dollars with independent, evidence-first reviews—and strengthens network integrity with licensing and credential audits of in-network and out-of-network providers.

When you don’t need a full program, you need precision. Aegis offers targeted, scope-defined audits that zero in on the pressure points you choose—preauthorization, coding/modifiers, medical necessity, payment accuracy, or any step in the claim journey. You get fast answers, defensible evidence, and measurable impact without the noise.

  • Scope exactly what you need — one service line, one provider group, one denial code, one edit: your call.
  • Deploy focused analytics to surface outliers and leakage patterns quickly.
  • Validate with policy-accurate clinical review to keep findings defensible and abrasion low.
  • Deliver action-ready results (root cause, financial impact, recommended fixes).
  • Enable rapid rollouts of edits, training, and provider education where warranted.

Menu of Focus Areas, including, but not limited to:

  • Preauthorization & Medical Necessity: criteria alignment, documentation sufficiency, frequency/duration rules.
  • Eligibility/Enrollment Linkage: plan design, effective dates, coordination of benefits.
  • Coding & Modifiers: upcoding/unbundling, modifier usage, place-of-service, units/time rules.
  • Site of Care & Setting: outpatient vs. office, ASC vs. hospital, OON exposure.
  • Payment Accuracy: fee schedules, multiple-procedure reductions, bilateral rules, bundling, carve-outs.
  • High-Risk Services: DME, lab/genetics, infusion, pain, imaging, telehealth, behavioral health, therapy.
  • Provider/Network Integrity: credentials, sanctions, ownership/affiliation patterns, ghost locations.
  • Denial Hotspots: top codes/payers, appeal outcomes, edit tuning to cut false positives.

How it Works:

  • Define the slice — you pick the scope, time window, plans, and objectives.
  • Pull and analyze data — targeted analytics to pinpoint where to look.
  • Validate — clinical/policy review to confirm issues and reduce noise.
  • Report & act — findings, overpayment estimates, edit/training recommendations, and provider outreach plan.

Pricing and Scope:

Pricing scales with data complexity, provider volume, focus areas, and plan mix. Fixed-fee pilots or phased engagements available.

  • Rapid scopes (single focus area or cohort): typically 2–4 weeks.
  • Expanded scopes (multi-focus, multiple lines of business): 4–8+ weeks.

Get a personal consultation.

Let’s chat about how we can work together.

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