Annual Wellness Visit Outreach: How to Increase AWV Completion Rates Without Adding Staff

Medical reviewer: Dr. Charles Sweet, MD, MPH. Annual Wellness Visits are among the highest-value preventive visits Medicare pays for, and most practices have more AWV revenue sitting in their panel than they're capturing. Here's the outreach playbook that moves completion rates from 20 percent to 60-plus.

The Annual Wellness Visit has been a covered Medicare benefit since 2011. In 2026, it pays approximately $175 to $250 per visit depending on whether it's an initial or subsequent AWV, the geographic adjustment, and any add-on codes for advance care planning or social determinants of health screening. For FQHCs billing under the Prospective Payment System, the AWV is bundled into a visit payment that runs substantially higher.

Despite that, national AWV completion rates hover around 20 to 30 percent of eligible Medicare beneficiaries. For the typical primary care practice managing a panel of 800 to 1,200 Medicare patients, that represents a gap of 500 to 900 unbilled AWVs per year, at an average of roughly $200 per visit, or $100,000 to $180,000 in unrealized annual revenue sitting in the panel.

None of that revenue requires new patients. It requires reaching the patients who are already on your panel, already eligible, and already nominally yours. What stops most practices is the coordination layer: identifying who's eligible, contacting them in a way that produces appointment bookings, and scheduling at a pace that fits the Medicare calendar.

This is the operational playbook for closing that gap.

Why are Annual Wellness Visit completion rates so low?

The patients who don't complete an AWV aren't avoiding healthcare. Most of them see their PCP for other reasons during the year. The gap is not a health-seeking gap. It's an outreach and scheduling gap.

Four structural reasons explain why AWV rates stay low.

First, patients don't know what an AWV is. The name suggests a physical, which Medicare does not cover outside of specific contexts. Patients who have ever been told Medicare doesn't cover a physical often assume that includes the AWV. They decline to schedule not because they don't want preventive care but because they believe they'll be charged.

Second, outreach is sporadic and manual. Most practices run AWV outreach either by having front-desk staff prompt patients at other visits (which misses patients who don't come in) or by running annual campaigns with handwritten lists and phone calls (which are labor-intensive and patchy). Neither approach scales to 800 Medicare patients.

Third, scheduling is friction-heavy. Even when a patient agrees to schedule an AWV, the process typically requires a phone call during business hours, a coordinator to check eligibility, and a slot that's often booked two to three weeks out. Patients who said yes in principle fall through by the time the appointment happens.

Fourth, AWVs compete with sick visits on the schedule. Practices that don't block AWV-specific slots find that AWVs get squeezed out by acute care demand. Patients calling for a wellness visit are told the next opening is six weeks away, which is not what a 75-year-old caller wants to hear.

These four issues are solvable operationally without adding staff. They require a different outreach and scheduling model.

Who is eligible for an Annual Wellness Visit, and how do you identify them?

CMS eligibility rules are specific, and getting them right matters both for patient experience and for billing compliance.

A Medicare beneficiary is eligible for the Initial Preventive Physical Examination (IPPE, also known as the Welcome to Medicare visit) once in their first 12 months of Medicare Part B enrollment. After that first year, they become eligible for the first AWV. Subsequent AWVs can be billed every 12 months thereafter, with “12 months” interpreted by CMS as at least 365 days from the last billed AWV date.

The practical implication for outreach is that your eligible patient list at any given moment includes every Medicare patient on your panel whose most recent AWV was more than 365 days ago (or who has never had one). That list can be generated from your EHR or from payer gap files, and it changes daily as patients age in and out of the 365-day window.

The common operational mistake is to run one annual outreach campaign in January or Q1. Because AWVs are eligible on a rolling 365-day cycle, a January campaign misses the patients who became eligible in February through December. A better approach is continuous eligibility monitoring with outreach triggered by the eligibility window opening.

Reviewing panel data alongside payer gap files also surfaces patients whose AWV was completed elsewhere. A Medicare Advantage patient who had an AWV at an urgent care six months ago is no longer eligible until the 12-month mark. Outreach that ignores this creates friction and makes the practice look disorganized.

What does a 5-step AWV outreach playbook look like?

The workflow that produces AWV completion rates of 60 percent and above follows a consistent pattern across practices that have implemented it.

Step 1: Identify eligible patients from the panel and payer gap files. Pull Medicare Part B and Medicare Advantage patients attributed to your practice whose last AWV was more than 335 days ago (giving a 30-day outreach runway). Reconcile against payer gap files to remove patients who had an AWV elsewhere. The output is a prioritized outreach list updated weekly.

Step 2: Stratify by recency and risk. Not all eligible patients get the same outreach. Patients who have never had an AWV get a different message than patients who had one 13 months ago. High-risk patients (multiple chronic conditions, recent hospital admissions) get prioritized for early outreach because their AWV drives more downstream care gap closure. Low-touch patients (stable, regular visitors) get lighter outreach because they're more likely to convert on a single message.

Step 3: Deploy multi-channel outreach. SMS first, because open rates are above 95 percent and response rates run 15 to 25 percent for well-crafted messages. Voice AI follow-up three to five days later for patients who don't respond to SMS. Email as a low-cost backup channel, with the caveat that email response rates for Medicare populations are substantially lower than SMS or voice. Each channel message explains what an AWV is in plain language (“a free preventive visit covered by Medicare, no copay”) and gives a direct path to scheduling. The deeper map on voice AI lives in AI voice scheduling and EHR integration.

Step 4: Offer instant self-scheduling. The SMS and email messages include a self-scheduling link that lets the patient book without calling the office. Voice AI outreach offers to book directly in the call. Both approaches convert 2 to 4x more than “call the office to schedule” messaging because they remove the phone call friction that disproportionately filters out the patients most likely to benefit from an AWV. See the scheduling solution for how this runs at the appointment layer.

Step 5: Automate reminders and no-show recovery. AWV no-show rates are higher than average because the visit isn't driven by an acute need. Reminders at 72 hours, 24 hours, and day-of reduce no-shows by 30 to 40 percent. When a no-show happens, automated outreach re-engages the patient within 48 hours with a rescheduling link, rather than waiting for the patient to call back (which they typically don't).

Practices running this workflow without automation need approximately one full-time coordinator per 500 AWV outreach cycles per year. Practices running this workflow with automation need a fraction of a coordinator FTE to handle exceptions, and the automation handles the throughput.

What completion rates are realistic for practices that automate AWV outreach?

The baseline and the ceiling are both well-documented.

The step function between “patient portal + reminders” and “multi-channel automated outreach” is the single largest lift available. Most Medicare patients are not active portal users. A portal-only strategy tops out in the low 50s because it cannot reach the half of the Medicare panel that doesn't log in. SMS and voice AI close the reach gap.

What's the revenue math on a 500-patient Medicare panel?

A mid-size primary care practice with 500 Medicare patients eligible for an AWV in any given year, running at a 25 percent baseline completion rate, captures 125 AWVs annually at an average of $200 per visit (blended between IPPE, initial AWV, and subsequent AWVs with standard add-ons). Revenue: $25,000.

The same practice running at 60 percent completion after implementing automated outreach captures 300 AWVs annually at the same average. Revenue: $60,000. Incremental revenue: $35,000.

That calculation understates the full opportunity in two ways. First, AWVs surface other billable services. The RPM setup visit, advance care planning add-on (G0468), SDOH screening add-on (G0136), and depression screening add-on can each add $30 to $75 to the billable amount when clinically appropriate. An AWV where the patient qualifies for multiple add-ons can bill $275 to $350.

Second, AWVs surface care gaps. A patient who comes in for an AWV gets their mammogram ordered, their diabetic eye exam referred, their A1C checked, their colorectal screening scheduled. Under value-based contracts, every care gap closed during or downstream of an AWV pays separately in quality bonuses and shared savings. For the ROI on referral automation that those downstream referrals run through, see the ROI math on AI referral automation.

When you model the full impact of closing the AWV completion gap, the $35,000 of direct AWV revenue is typically the smaller piece of a $75,000 to $125,000 total annual uplift per 500-patient panel.

What should FQHCs pay attention to differently?

FQHCs operate under different billing rules and different quality reporting obligations than independent primary care practices. Three differences matter for AWV strategy.

First, FQHC AWV payment flows through the PPS bundled rate rather than the Medicare Physician Fee Schedule. The bundled rate varies by HRSA region but typically runs $175 to $225 for a face-to-face visit, with similar payment when a patient has an AWV as with other visit types. The revenue upside from closing the AWV gap is similar, but the billing mechanics are different.

Second, UDS reporting and HRSA quality measures make AWVs more than a billing opportunity. UDS measures on preventive screening, diabetes management, and cardiovascular risk all benefit when AWVs happen because the AWV is where care gaps are identified and addressed. FQHCs missing AWV completion are also missing downstream UDS numerators on connected measures. See also FQHC care gap closure with AI.

Third, FQHCs serving substantial LEP (Limited English Proficiency) populations need AWV outreach that works in the patient's preferred language. Single-language SMS campaigns underperform in FQHC settings by 40 to 60 percent compared to multilingual outreach. This is the place where the FQHC outreach model has to diverge from a generic primary care playbook.

“The AWV outreach piece changed how we managed our Medicare panel. We went from chasing a handful of completed visits to a continuous flow, and the downstream care gap closure came with it. It made our quality reporting a different conversation internally.”

Best fit and less ideal fit

The AWV outreach playbook fits best for: primary care practices managing 200 or more Medicare patients, FQHCs with Medicare and Medicare Advantage panels, ACO participating organizations where AWV completion flows through shared savings calculations, accountable care primary care groups in two-sided risk contracts.

The playbook is less ideal for: specialty practices without primary care scope (AWVs are billed by PCPs, not specialists), practices where the Medicare panel is under 100 patients (the labor investment doesn't clear ROI at that volume without broader automation), practices whose provider capacity cannot accommodate the lift in AWV volume (the outreach produces bookings that require open slots; implementation has to coincide with AWV slot blocking in the schedule template).

Frequently asked questions

What's the difference between the IPPE, Initial AWV, and Subsequent AWV?

The Initial Preventive Physical Examination (IPPE, billed as G0402) is the “Welcome to Medicare” visit, billable once in the first 12 months of Part B enrollment. The Initial Annual Wellness Visit (G0438) is billable once, at least 12 months after Part B enrollment and at least 12 months after an IPPE if one was billed. Subsequent AWVs (G0439) are billable every 12 months thereafter. Reimbursement differs slightly among the three. Billing the wrong code is a common denial reason, which is why eligibility checking before the visit matters.

Is an AWV the same as an annual physical?

No, and the distinction is important for patient communication. Medicare does not cover an annual physical the way commercial insurance does. An AWV is a preventive care planning visit that includes a health risk assessment, review of medications, cognitive and functional screening, and development of a personalized prevention plan. It does not include the head-to-toe physical examination patients may be expecting. Setting this expectation clearly in outreach messaging reduces patient confusion and improves completion because it prevents patients from declining based on a misunderstanding.

Can an AWV be done via telehealth?

CMS has allowed AWVs to be billed via telehealth under specific public health emergency and post-PHE provisions. As of 2026, telehealth AWVs remain billable when conducted via real-time audio and video communication, though specific telehealth rules vary by payer (Medicare Fee-for-Service, Medicare Advantage, and FQHC-specific rules each have nuances). Telehealth AWVs typically convert patients who would otherwise decline an in-office visit, and the completion lift from offering both modalities is substantial.

How does the AWV interact with HEDIS and STARS measures?

The AWV is not itself a HEDIS measure, but it's the highest-leverage visit for closing care gaps that are measured. Colorectal cancer screening, breast cancer screening, diabetic eye exams, A1C testing, controlling blood pressure, and medication reconciliation are all commonly addressed during an AWV. Practices with high AWV completion rates consistently outperform on the connected HEDIS measures.

What billing compliance issues come up with AWV outreach at scale?

Three recurring issues. First, billing a subsequent AWV fewer than 365 days after the last one creates a denial and a refund obligation. Second, billing an IPPE after the 12-month Part B window is a denial. Third, billing both the AWV and a problem-oriented E&M on the same day requires separate documentation and a modifier (-25 on the E&M), and shortcutting this creates audit risk. Eligibility checking before outreach reduces the first two. Clear documentation practices reduce the third.

Pulling it together

The AWV completion gap is among the clearest examples of revenue sitting unclaimed in a primary care panel. The reason it stays unclaimed isn't clinical complexity or patient unwillingness. It's the coordination and outreach layer. Practices that fix the layer close the gap.

A 500-patient Medicare panel running at 25 percent AWV completion has roughly $100,000 in direct and downstream revenue available from closing the gap. The operational cost of capturing it, with the right outreach workflow, is a fraction of a coordinator FTE.