Annual Wellness Visits and Preventive Care: How AWVs Help Close Care Gaps

Published on

September 23, 2025

On a crisp Monday morning, Jane, a 72-year-old patient arrives at a rural clinic for her Medicare Annual Wellness Visit (AWV). Over the past year, Jane has seen her doctor five times, each visit tackling an immediate issue (a urinary tract infection, back pain, a medication refill, a blood-pressure check, a cough), however, none of those problem-focused encounters offered an opportunity for an holistic review. There simply was never time for it. During the AWV, the care team has the opportunity for a comprehensive review with the patient, and can step back and see the full picture: Jane is overdue for a mammogram, hasn’t had her flu shot, and would benefit from chronic care management for diabetes. The AWV becomes the pause that prevents things from slipping through the cracks.

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Why Annual Wellness Visits matter

Annual Wellness Visits have grown into one of CMS’s most important preventive care levers. Their significance goes beyond eligibility and coverage, as they fundamentally reshape how practices surface unmet needs and improve population health:

Growing but still underused. Recent CMS survey data show that AWV uptake rose from about 45% of community-dwelling beneficiaries in 2020 to roughly 60% in 2022. That’s progress, but it still means 4 out of 10 Medicare patients miss the opportunity each year. For practices in value-based arrangements, that gap is costly, as every missed AWV is a cluster of preventive services and quality points left on the table.

Quantifiable gains in preventive service use. Multiple peer-reviewed studies demonstrate AWVs dramatically increase the uptake of evidence-based preventive services. In one large study, beneficiaries completing an AWV were 22 percentage points more likely to receive mammography within six months. Another found higher utilization of eight different preventive services, including colorectal cancer screening, vaccinations, and smoking-cessation counseling, within one year. These are not marginal gains; they are population-level shifts that directly improve health trajectories.

Impact on safety and function. AWVs are also linked to lower risks of falls (–3.9%) and fractures (–4%), with stronger fall-reduction effects among rural patients. This matters for practices whose patients struggle with frailty, mobility, or home safety. Identifying and mitigating fall risk during AWVs translates to fewer hospitalizations, less functional decline, and lower long-term costs.

Cost savings without compromising quality. One analysis found AWVs were associated with 5.7% lower total costs over the following year, even though ED and inpatient utilization did not change significantly. That reduction reflects earlier detection of conditions, fewer late-stage complications, and better alignment with preventive guidelines. For practices, this is powerful evidence: AWVs don’t just check CMS boxes: they bend the cost curve while improving care.

Strategic importance for quality and revenue. In the quality-payment landscape, AWVs are a structural advantage. Many MIPS and Medicare Advantage Star Rating measures overlap directly with AWV content, including cancer screening, immunizations, risk-factor assessments, and depression screening. A higher AWV completion rate improves measure performance, strengthens shared-savings payouts, and boosts Medicare Advantage bonus payments. In other words: every additional AWV done systematically compounds into both better care and stronger financial performance.

Together, these data position the AWV as a practical engine for prevention and risk reduction rather than an administrative exercise.

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How AWVs help close care gaps, especially for chronic conditions

AWVs surface “hidden opportunities” that rarely get addressed in problem-focused visits, and then orchestrate timely follow-through.

Cancer screening alignment. Overdue colon, breast, or lung screening is identified and ordered on the spot, bundling downstream steps (imaging, FIT, LDCT) into a coordinated plan.
Immunization catch-up. Pneumococcal, shingles, influenza, and COVID-19 status is reconciled; use standing orders or same-day administration to close the loop.
Cardiovascular risk activation. Repeated borderline BPs across the chart prompt ambulatory monitoring or RPM enrollment and a medication titration plan, replacing “watch and wait” with a protocolized approach.
Diabetes gap cascade resolution. Missing A1c, retinal, foot, or nephropathy checks are reconciled in a single plan, with orders placed and Chronic Care Management (CCM) enrollment triggered for longitudinal follow-through.
COPD/asthma optimization. Inhaler technique and adherence are reviewed; spirometry, respiratory education, pulmonary rehab, or remote peak-flow tracking is queued for early exacerbation detection.
CKD vigilance. Rising creatinine or albuminuria cues nephrology referral and integration of kidney metrics into the prevention plan.
Polypharmacy and de-prescribing. Medication reconciliation often reveals low-value or duplicative meds (e.g., long-term PPIs, redundant statins) suitable for tapering.
Behavioral health integration. Positive screens for depression, anxiety, or cognitive concerns lead to warm handoffs into integrated behavioral services aligned with the patient’s chronic-disease goals.

Problem-oriented visits are almost always focused on the acute issue of the day. A patient may come in for a cough, a backache, or a refill, and the visit ends when the immediate concern is resolved. The AWV is different: it’s structured to zoom out and surface unmet preventive and chronic-care needs that get pushed aside in busy schedules. This makes the AWV uniquely powerful for chronic disease management, where success depends on consistent monitoring, lifestyle interventions, and coordination across multiple providers.

Here are some examples of how AWVs can help impact some chronic conditions:

Diabetes

Gap detection: Many patients miss their annual A1c test, diabetic eye exam, or foot exam.
AWV intervention: The AWV template forces a review of these metrics. Orders can be placed immediately, and referrals to ophthalmology or podiatry scheduled before the patient leaves.
Next step: High-risk patients can be directly enrolled into Chronic Care Management (CCM) or Remote Patient Monitoring (RPM) programs for glucose or weight tracking, ensuring continuous oversight.

Hypertension and cardiovascular disease

Gap detection: Elevated readings are often scattered across the chart without a cohesive plan.
AWV intervention: The AWV prompts review of longitudinal vitals. Multiple elevated readings over the year can trigger guideline-based action—such as ambulatory BP monitoring or medication titration.
Next step: Patients can be enrolled in RPM for blood pressure, creating structured follow-up and reducing the risk of stroke or MI.

COPD and asthma

Gap detection: Inhaler technique and adherence are rarely reviewed in routine visits. Spirometry may be overdue.
AWV intervention: The AWV checklist ensures smoking status is reviewed, adherence assessed, and preventive services like flu or pneumococcal vaccination confirmed.
Next step: Patients can be referred to pulmonary rehab or set up with remote peak flow monitoring for earlier detection of exacerbations.

Chronic kidney disease (CKD)

Gap detection: Rising creatinine or abnormal urine protein results may not trigger referrals in problem-focused care.
AWV intervention: Review of labs during the AWV highlights renal risk, prompting nephrology referral and tighter monitoring.
Next step: Kidney function is integrated into the prevention plan, including medication review to avoid nephrotoxic agents.

Polypharmacy and de-prescribing

Gap detection: Patients with multiple chronic conditions are often on 10+ medications, many outdated or duplicative.
AWV intervention: Medication reconciliation is required, and the AWV creates time to consider de-prescribing, such as tapering long-term PPIs, stopping duplicate statins, or reevaluating sedative use.
Next step: Simplified regimens improve adherence and safety, and de-prescribing reduces fall risk in frail or rural patients with limited follow-up options.

Behavioral health and cognitive decline

Gap detection: Mild depression, anxiety, or early cognitive impairment often go undetected until advanced.
AWV intervention: Required depression and cognitive screening tools surface these issues early.
Next step: Patients can be referred into Behavioral Health Integration (BHI) or community services, aligning mental health care with chronic disease management.

Why this matters for practices: Every chronic condition has a set of “silent gaps” (overdue labs, missed screenings, unreviewed meds, lack of referrals). The AWV forces a structured audit of those gaps, and because the patient is already in the clinic, providers can act immediately: ordering, referring, or enrolling on the spot. This is especially critical for rural practices, where patients may not return for months and where access to specialists is limited.

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Implementation strategy: turning AWVs into a consistent engine

Many practices treat AWVs as “bonus visits” sprinkled into the schedule. The practices that extract their full preventive and financial value treat AWVs as a core operating line. That means building AWVs into the rhythm of scheduling, outreach, documentation, and follow-up so they become predictable and scalable:

1. Build an AWV registry and track eligibility dynamically.

Use your EHR or population-health platform to maintain a live list of Medicare patients and their AWV eligibility dates.
Flag patients 11 months after their last AWV so scheduling can be proactive rather than reactive.
Stratify by risk: prioritize patients with multiple chronic conditions, long gaps in care, or those in value-based contracts.

2. Treat AWVs as their own service line.

Block dedicated AWV slots weekly so they aren’t squeezed out by acute-visit demand.
Train schedulers to promote AWVs when patients call for unrelated issues (“You’re due for your AWV, let’s schedule it at the same time.”).
Assign ownership: designate a “preventive care coordinator” who is accountable for AWV completion rates.

3. Standardize workflows with team-based delegation.

MAs or nurses collect vitals, update histories, reconcile meds, complete health risk assessments (HRAs), and trigger standing orders for labs and vaccines.
Physicians or NPs synthesize findings, finalize prevention plans, and handle shared decision-making.
Behavioral health or care coordinators review screenings for depression, falls, or cognition and facilitate warm handoffs.

4. Integrate AWVs with other longitudinal programs.

Build protocols so that patients flagged for uncontrolled diabetes, hypertension, COPD, or CHF are immediately assessed for CCM or RPM enrollment.
Embed referral prompts for behavioral health, nutrition counseling, or community resources into AWV templates.
Make the AWV the front door for ongoing care management programs.

5. Close the loop in real time.

Order overdue labs, imaging, or vaccines during the AWV rather than deferring.
Use standing orders to allow same-day vaccine administration.
Schedule follow-up visits before the patient leaves, e.g., “your diabetic eye exam is booked two weeks from now.”

6. Monitor and improve relentlessly.

Track AWV completion rates monthly; aim for 70%+ of eligible patients.
Audit charts to confirm preventive gaps are closed, not just documented.
Hold quarterly quality meetings to review AWV performance and adjust workflows (e.g., refine scripts, expand outreach channels, or add tele-AWV options especially for rural patients).

7. Adapt for rural and underserved patients.

Offer hybrid models: HRAs completed by phone or patient portal in advance, with a shorter in-person or telehealth AWV follow-up.
Partner with community centers, churches, or pharmacies to host mobile AWV days.
Use cellular-connected devices to extend RPM and other follow-up programs where broadband is limited.

Bottom line: An AWV strategy should run like a production line: patients identified, scheduled, processed through a standardized workflow, and followed up with systematic gap closure. Once embedded into clinic operations, AWVs shift from “extra work” to a predictable source of preventive care, quality performance, and downstream revenue.

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ROI and practice benefits

Annual Wellness Visits are unique in that they deliver value across three domains: clinical outcomes, operational performance, and financial return. When practices treat AWVs as a core service line rather than an optional add-on, the benefits are both measurable and sustainable:

Clinical ROI

Better preventive coverage. AWV recipients are significantly more likely to receive guideline-based cancer screenings, vaccinations, and risk-factor assessments. A 2024 study showed a 22-percentage-point increase in mammography uptake among patients completing an AWV.
Lower risk of complications. AWVs have been linked to a 3.9% reduction in falls and a 4% reduction in fractures, with especially strong impact in rural patients. These outcomes reduce morbidity, improve quality of life, and prevent expensive acute episodes.
Chronic disease control. By surfacing and addressing missed labs, overdue follow-ups, and unaddressed comorbidities, AWVs drive tighter management of diabetes, hypertension, COPD, and CKD, thus reducing downstream ED use and hospitalizations.

Operational ROI

Improved quality scores. AWVs align directly with quality metrics in MIPS, ACO benchmarks, and Medicare Advantage Star Ratings. Higher completion rates translate into better measure performance across cancer screening, immunization, depression screening, and chronic condition management.
Stronger value-based contracting position. Closing care gaps during AWVs helps practices achieve thresholds for shared savings or performance bonuses. Even small improvements in quality scores (e.g., 2–3 percentage points) can shift a practice from average to high-performing.
Care coordination synergy. AWVs create a pipeline into CCM, RPM, and BHI programs, which improves continuity and distributes workload across the care team. This reduces provider burnout and builds operational resilience.

Financial ROI

Reimbursement and downstream returns vary by locality and payer contracts, but conservative estimates show AWVs can quickly become profitable (note the figure below are for illustrative purposes, actual figures depend on the specific programs available in your state):

Direct reimbursement. Average Medicare reimbursement: ~$200 per AWV (G0438 for initial, G0439 for subsequent). A panel of 500 eligible patients, with a 60% completion rate (300 AWVs/year), yields ≈ $60,000/year in direct AWV revenue.

Downstream preventive services. Each AWV typically uncovers 1–2 missed screenings or immunizations. If 300 AWVs uncover 400 gaps, and each yields an average of $100 in billable services, that’s $40,000 in additional revenue.

Care management enrollment. If 25% of AWV patients (≈75) are enrolled in CCM or RPM at ~$80 PMPM, that’s ≈ $72,000/year recurring revenue.

Value-based contract upside.Closing an additional 50–100 care gaps per 1,000 attributed patients can shift Star Ratings or MIPS composite scores, unlocking $20,000–$50,000 in shared savings or incentive payments.

Total impact: In a small-sized practice with 500–1,000 Medicare patients, AWVs can reasonably generate $150,000–$250,000 annually when accounting for direct billing, downstream services, care-management enrollment, and incentive bonuses. For larger systems or ACOs, the impact scales into the millions.

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Key take-aways on AWVs

Annual Wellness Visits are far more than a Medicare box to check. They are the structured opportunity to step back, review the patient’s whole health picture, and systematically close care gaps that otherwise persist year after year, including screenings, immunizations, chronic condition follow-ups, behavioral health needs, and even social risk factors. When AWVs are conducted systematically, practices see measurable improvements in patient outcomes, stronger quality scores, and significant new revenue streams from both direct reimbursement and downstream programs like CCM, RPM, and BHI.

However, making AWVs a reliable, high-impact service line takes consistency, workflows, and follow-through, and that’s where Lara Health can help:

Systematic workflows. Lara Health embeds AWV templates and checklists directly into the platform, ensuring every required element is captured, from health risk assessments to personalized prevention plans.
Team-based execution. The platform supports delegation to MAs and nurses for intake, risk assessments, and screenings, while surfacing what requires clinician review, reducing bottlenecks and making AWVs scalable.
Gap closure in real time. Lara Health integrates preventive care logic, so overdue screenings, vaccines, or labs are flagged automatically and scheduled during the AWV rather than deferred.
Integration with CCM/RPM. Patients identified with chronic conditions can be seamlessly enrolled in care management or remote monitoring programs during the AWV, creating continuity and unlocking recurring revenue.
Hybrid and remote flexibility. Lara Health supports both in-person and tele-AWV models, enabling practices to reach patients in rural or underserved areas who might otherwise skip preventive visits. Patients can complete portions of the AWV remotely, with clinicians finalizing the plan virtually.
Audit-ready documentation. Every AWV is captured with the documentation CMS requires, linked to care gap reporting and quality measure dashboards, ensuring practices are prepared for audits and performance reviews.

In short, Lara Health turns the AWV from a once-a-year “checkup” into a consistent engine for prevention, chronic care, and revenue growth. By making AWVs easier to schedule, execute, document, and follow through, practices can meet patients wherever they are (in the clinic, at home, or virtually) and deliver better outcomes while securing their financial sustainability. Book a demo with Lara Health to see how we can help your practice run a consistent, optimized AWV program that closes more care gaps and supports both in-person and remote visits.

FAQs

What is a Medicare Annual Wellness Visit (AWV)?

An AWV is a yearly, Medicare-covered appointment focused entirely on prevention and risk assessment. It reviews health history, screenings, immunizations, and risk factors, and creates a personalized prevention plan. It is not a head-to-toe physical exam but a structured preventive care visit.

How often can Medicare patients get an AWV?

Medicare covers one Initial AWV (G0438) in the first year a patient is eligible, and one Subsequent AWV (G0439) every 12 months thereafter. Patients must wait 12 full months between AWVs.

How do AWVs help close care gaps?

AWVs systematically identify missed screenings, vaccines, and chronic care follow-ups. For example, an AWV may reveal overdue colonoscopies, diabetes A1c tests, or missed flu shots. Addressing these gaps improves patient outcomes and boosts practice performance on quality measures.

Are AWVs reimbursed by Medicare?

Yes. AWVs are reimbursable encounters. Average reimbursement is around $200, depending on locality and coding. Practices also benefit from downstream revenue, like new preventive services, CCM/RPM enrollment, and improved value-based payment incentives.

How are AWVs different from a physical exam?

A physical exam focuses on diagnosing or treating specific problems. An AWV is preventive and focused on risk assessment, screening history, and developing a personalized prevention plan. Medicare does not cover routine physicals, but it does cover AWVs.

Do AWVs improve health outcomes?

Evidence shows AWVs increase preventive service use, such as mammography and vaccinations, and are linked to reduced falls and fractures, especially in older and rural populations. They also help manage chronic conditions more consistently, reducing long-term costs.

What is the ROI for practices offering AWVs?

AWVs typically generate $175-$250 per visit in direct reimbursement, plus additional revenue from closing care gaps and enrolling patients into CCM or RPM programs. A practice with 500 Medicare patients could generate $150,000-$250,000 annually in combined direct and downstream revenue.

How can Lara Health help with AWVs?

Lara Health provides AWV workflows, templates, and checklists; supports team-based execution; integrates preventive logic to flag overdue services; and enables hybrid in-person and tele-AWVs. It also connects AWVs directly to CCM, RPM, and quality reporting, making them consistent, scalable, and audit-ready.

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Sources

CMS Medicare Current Beneficiary Survey.

Hamer MK et al., Journal of General Internal Medicine.

Jiang M et al., Preventive Medicine.

Beckman AL et al., American Journal of Managed Care.

Tzeng HM et al., Preventive Medicine.

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