How to Automate Medicare Routine Claim Scrubbing and Submission (Without Compliance Risks)

The claims look simple.

Basic services. Routine visits. Standard codes.

You’ve submitted them hundreds of times before.

So why are they still eating up your team’s time?

Because with Medicare, even your most routine claims demand:

• Exact CPT/ICD-10 pairings
  
  
  

• Modifier logic aligned to LCDs and NCDs
  
  
  

• Documentation that meets constantly shifting MAC expectations
  
  
  

It’s not the complex cases slowing you down. It’s the repeatable, high-volume workflows that should be frictionless… but aren’t.

Every flagged claim still triggers a manual review.

Every submission still happens in real time, across multiple systems.

And every step introduces risk: compliance gaps, delays, denials, audits.

Here’s the good news: those steps are automatable.

We’re not just talking about “AI in healthcare.”

We’re showing how real RCM teams are automating Medicare claim scrubbing and submission, without violating compliance protocols or payer rules.

Let’s break it down.

Why Medicare Routine Claims Are Anything But Simple

“Routine” doesn’t mean “low risk.”

If anything, routine Medicare claims—labs, follow-up visits, diagnostics, and screenings—carry some of the highest compliance pressure in RCM.

Why? Because they happen hundreds or thousands of times per week, and each one has to hit a moving target:

• Local Coverage Determination (LCD) rules
  
  
  

• Modifier logic
  
  
  

• Diagnosis–procedure code alignment
  
  
  

• Submission formatting that varies by MAC
  
  
  

• Documentation requirements that shift quarter to quarter
  
  
  

When you're submitting that volume of claims to Medicare, any small error scales quickly into:

• Denials
  
  
  

• Resubmissions
  
  
  

• Manual rework
  
  
  

• Delayed reimbursement
  
  
  

• MAC audits
  
  
  

The Volume Problem: Routine Claims Make Up 80–90% of Medicare Submissions

Let’s look at the data:

According to CMS Medicare Claims Data, over 90% of Part B claims processed in 2023 were for routine services like labs, screenings, and E/M visits.

And most of them include:

• CPT codes that look familiar (e.g., 36415, 99213, 80053)
  
  
  

• Modifiers that must reflect medical necessity (e.g., 25, 91)
  
  
  

• ICD-10 codes that need to match the MAC’s LCD precisely
  
  
  

The Medical Group Management Association (MGMA) found that routine coding issues—modifier misuse, LCD mismatches, and missing documentation—accounted for 47% of Medicare denials in multispecialty clinics.

The Risk Problem: More Volume = More Scrutiny

MACs are watching. CMS is tracking. And Medicare billing audits increasingly target high-frequency CPTs billed without:

• Justifying ICD-10 codes
  
  
  

• Appropriate modifier use
  
  
  

• Evidence of medical necessity
  
  
  

The result?

• Repetitive denials that block cash flow
  
  
  

• Prepayment reviews for entire service lines
  
  
  

• Staff exhaustion from doing the same fix 50+ times a week
  
  
  

In 2024, OIG audit data highlighted routine tests billed under modifier 91 as a high-risk area for improper payments across multiple MACs.

The Workflow Problem: Manual Scrubbing and Submission Is Still the Norm

Here’s what “routine” looks like inside most billing departments:

1. Claim is generated in the EHR
   
   
   

2. Staff manually validates CPT + ICD-10 pairing
   
   
   

3. Adds modifier (maybe)
   
   
   

4. Scrubber flags LCD mismatch
   
   
   

5. Someone finds the LCD, updates diagnosis
   
   
   

6. Claim is manually resubmitted via MAC portal
   
   
   

7. Team logs change in a spreadsheet or ticketing tool
   
   
   

Repeat. Repeat. Repeat.

Each “simple” claim takes 5–10 minutes, and introduces a dozen places for human error.

Visual Opportunity: The Real Workflow for a Routine Claim

Routine doesn’t mean easy. It means it should be automated.

Routine = Risk, Delay, and Burnout

Medicare routine claims aren’t simple—they’re where most of your time, denials, and audit risk live.

And as volumes increase and compliance gets tighter, manual workflows simply won’t scale.

Scrub First, Submit Fast: How to Layer Automation on Top of Claim Scrubbers

Scrubbers are essential, but incomplete. They tell you when something’s wrong with a Medicare claim.

But they don’t fix it. 

They don’t move across systems.

They don’t resubmit the claim.

And they definitely don’t log the update for audit readiness.

Your scrubber is your alarm. Automation is your response team.

To truly scale Medicare routine claim management, smart RCM teams are layering automation on top of their scrubber alerts, so the right agent takes action the moment a flag appears.

How Scrubbers Work (and Where They Stop)

Most modern claim scrubbers (Waystar, Optum, FinThrive, Experian) are configured to:

• Cross-check CPT/ICD-10 codes for LCD/NCD alignment
  
  
  

• Flag modifier misuse (e.g., 25, 91, 59)
  
  
  

• Detect medically unnecessary services (per payer policy)
  
  
  

• Catch frequency violations and missing documentation
  
  
  

But here’s where they stop:

A 2024 Kaufman Hall survey found that over 55% of claim denials related to Medicare LCDs were flagged pre-submission, but never corrected due to staff bottlenecks.

The Automation Layer: From Alert to Action in Seconds

This is where Magical’s AI agents come in.

Your scrubber flags the issue.

Magical takes it from there.

Here’s what that looks like in real workflows:

Scenario 1: Modifier 91 Missing on a Repeat Lab Test

• Scrubber flags the omission
  
  
  

• Magical locates the original test entry
  
  
  

• Applies Modifier 91 to repeat CPT code
  
  
  

• Navigates to MAC submission portal
  
  
  

• Submits corrected claim
  
  
  

• Logs action in internal billing dashboard
  
  
  

Total time saved: 8–10 minutes per claim

Scenario 2: CPT–ICD Mismatch for LCD L37079 (Noridian)

• Scrubber flags denial risk for routine screening
  
  
  

• Magical pulls updated ICD-10 from documentation
  
  
  

• Replaces incorrect code in claim form
  
  
  

• Resubmits directly via clearinghouse
  
  
  

• Notifies billing lead + logs timestamped correction
  
  
  

No PDF hunting. No toggling. No delay.

Scenario 3: High-Volume Batch of Lab Claims Flagged for Missing Justification

• Magical scans all flagged claims
  
  
  

• Identifies missing A1C or encounter note
  
  
  

• Matches documentation to claim
  
  
  

• Bundles and submits corrected batch to MAC
  
  
  

• Logs correction path + notes for audit readiness
  
  
  

Claim scrubber ≠ claim solution. Magical closes the loop.

Why Magical Works: Focused AI, Not Generic Automation

Magical isn’t a macro tool or rules-based workflow hack.

It’s powered by AI agents that:

• Understand payer logic
  
  
  

• React to structured and unstructured data (PDFs, portals, EHR fields)
  
  
  

• Execute across systems (EHRs, billing tools, payer portals)
  
  
  

• Work 24/7 without needing to “remember” which LCD applies where
  
  
  

That’s how billing teams are finally closing the loop between claim scrubber alerts and paid, audit-proof claims, without more staff or more time.

Final Thoughts: Clean, Compliant, and Scalable: The Future of Medicare Claim Management

You don’t need a bigger billing team. You need a smarter system.

A system that flags errors early. Fixes them fast. Submits with confidence.

And logs every step for audit readiness.

That’s what modern RCM teams are building—especially when it comes to high-volume, high-risk Medicare claims.

Because they’ve learned the hard way that routine doesn’t mean easy—it means:

• Easy to miss
  
  
  

• Easy to repeat
  
  
  

• Easy to break… at scale
  
  
  

So instead of throwing more people at the problem, they’re using scrubbers for precision and AI agents for execution.

Why This Matters Now

Medicare policies are changing faster than ever. MACs are tightening LCD enforcement.

Denials are trending up.

And billing teams are already stretched thin.

According to the AAPC, over 61% of coders and billers report increased workloads tied to modifier use, LCD documentation, and repeat claim resubmissions.

That’s why the organizations winning in 2025 are those who’ve embraced a hybrid approach:

• Use scrubbers to catch it
  
  
  

• Use Magical to fix it
  
  
  

That’s how they’re turning what used to be 10-minute claim tasks into fully automated flows, without sacrificing accuracy or compliance.

Try Magical Free & Stop Wasting Time on Routine Claim Rework

Magical isn’t just an automation platform.

It’s the bridge between flagged and fixed—built for high-volume Medicare workflows and trusted by over 100,000 companies and 1 million users.

Install the free Magical Chrome extension and let your AI agents:

• Handle routine scrubber flags
  
  
  

• Fix modifier, ICD, and LCD issues
  
  
  

• Submit directly through MAC portals
  
  
  

• Log changes for audit-proof billing
  
  
  

Because your team has better things to do than reworking claims that should’ve been paid the first time.