Annual Wellness Visits: How ACOs Can Build the First Layer of Scalable Care Capacity

By Jay Chowdappa, MD, co-founder and CEO, Zynix AI · Updated November 3, 2026

Key takeaways

ACOs build scalable care capacity by starting with the Annual Wellness Visit: Medicare covers it once every 12 months, at no cost when the provider accepts assignment, and each visit produces a prevention plan before problems escalate. Run it as a continuous workflow, not a campaign: trusted due lists, prioritized outreach, booking, no-show recovery, visit preparation and owned follow-up.

• Medicare covers the AWV once every 12 months to create or update a personalized prevention plan, with a health risk assessment, a review of history and prescriptions, and a written checklist of screenings and vaccines.
• Because it reaches patients before a hospitalization, a missed screening or a rising-risk signal, the AWV moves an ACO upstream of reactive work such as post-discharge follow-up and care gap closure.
• AWV programs usually stall on capacity rather than intent: fragmented eligibility lists, too little staff time for repeated outreach, unrecovered no-shows and next steps with no owner.
• Digital workers fit the high-volume, rules-based steps such as worklists, voice and SMS outreach, reminders and no-show recovery, while care planning, clinical review and escalations stay with the care team.
• Judge the program on the full workflow, from eligibility and contact through completed visits and closed follow-up tasks, not on outreach volume alone.

ACOs often treat Annual Wellness Visits (AWVs) as a scheduling target and that is a narrow perspective. An AWV is one of the earliest structured opportunities to understand the patient, update the prevention plan, identify risk factors, surface care gaps, and create a care relationship before the patient deteriorates. That makes it one of the best starting points for building scalable care capacity.

Transitional care management matters. Post-discharge follow-up matters. Care gap closure matters. But those workflows often begin after something has already happened: a hospitalization, a missed screening, an unresolved condition, a rising-risk signal. AWV starts earlier. It gives the ACO a way to move upstream, before avoidable utilization and before care teams are forced into reactive work.

Medicare describes the Annual Wellness visit as a once-every-12-month preventive visit used to develop or update a personalized prevention plan based on current health and risk factors. It includes Health Risk Assessment, routine measurements, medical and family history review, current prescription review, preventive recommendations, advance directive discussion, and cognitive assessment.

In other words, it is not just a visit. It is a structured care-planning moment.

For ACOs, the question is not simply, "How do we complete more AWVs?" but the better question is: "How do we build a repeatable operating model that helps every eligible patient get reached, scheduled, prepared, seen, and followed up with?" That is where scalable care capacity begins.

Why AWV Matters for Shared Savings and Patient Care

The Medicare Shared Savings Program describes ACOs as groups of doctors, hospitals, and other providers who collaborate to deliver coordinated, high-quality care to people with Medicare, focusing on the right care at the right time while avoiding unnecessary services and medical errors.

When an ACO succeeds in high-quality care and spends healthcare dollars more wisely, it may be eligible to share in the savings it achieves. AWV supports that model because it connects prevention, engagement, quality, and care planning in one workflow.

The shared savings story should not be framed as cost reduction alone. The stronger angle is better patient care through earlier connection. An AWV can help identify the patient who has stopped taking medication correctly. It can surface a fall risk before an injury. It can create a plan for screenings before a quality gap becomes a performance issue. It can reconnect a patient who has not seen the practice in months.

The visit itself is important. The follow-through after the visit is where the ACO operating model is tested.

Where AWV Workflows Break Down

Most ACOs do not need to be convinced that AWVs matter. The challenge is capacity. The workflow looks simple on paper: identify eligible patients, reach them, explain the visit, schedule the appointment, remind them, prepare the practice, complete the visit, document the result, and route next steps. In practice, each step creates friction.

This is not a people problem. It is a capacity design problem. Care teams carry the trust, local context, and clinical judgment that make AWV valuable. But they are being asked to handle more patients, more contracts, more quality requirements, more outreach, and more documentation.

Adding people helps, but it scales linearly. If the eligible population doubles, the outreach burden doubles. If more practices join the ACO, workflow variation expands. If the ACO takes on more risk, the follow-up load grows again. A better model is needed: one where human teams remain central, but repeatable work does not depend on manual effort at every step.

The AWV Capacity Model ACOs Need

ACOs should treat AWV as a full operating workflow, not a campaign. A campaign asks, "How many patients did we call this month?" A capacity model asks, "Can we continuously identify, reach, schedule, prepare, complete, and follow up with eligible patients across the network?" That difference matters. A scalable AWV model should include six layers.

Reliable Eligibility

The ACO needs one working view of who is eligible, who is overdue, who recently completed a visit, and which practice owns the relationship. Without this, outreach becomes noisy and staff lose confidence in the list.

Smart Prioritization

Not every eligible patient should be treated the same way. Patients should be segmented by risk, care gaps, chronic conditions, engagement history, language needs, practice relationship, and prior utilization. That allows the care team to focus human time where it matters most.

Patient-Centered Outreach

AWV outreach should not sound like an administrative reminder. It should explain why the visit matters: updating the prevention plan, reviewing risks, identifying screenings, and helping the care team understand what support the patient may need next.

Scheduling and No-Show Recovery

Outreach only matters if it converts into a completed visit. ACOs need scheduling support, reminder workflows, and a recovery path when patients miss appointments.

Visit Preparation

The practice should see the right context before the patient arrives: open gaps, risk signals, medication concerns, recent utilization, and unresolved follow-up needs. The goal is not another report. The goal is useful context at the point of care. Our pre-visit planning checklist covers what to prepare and who owns each item.

Post-Visit Follow-Through

The AWV may create tasks: screenings, vaccines, referrals, medication review, chronic care support, nutrition counseling, home safety review, behavioral health follow-up, or care management outreach. If those steps are not routed and completed, the AWV becomes a documentation event instead of a care-planning workflow.

Where AI Digital Workers Fit

AI digital workers are most useful when work is high-volume, repeatable, measurable, and rules-based, but still dependent on timely handoff to humans. AWV fits that profile. Digital workers can support the care team by handling the operational steps that slow the system down: build and refresh eligible patient worklists, segment patients by priority and outreach pathway, conduct voice or SMS outreach, explain the value of AWV in patient-friendly language, support scheduling and reminders, recover no-shows, document outreach attempts, trigger next-step tasks after the visit, and route barriers, questions, and clinical concerns to human teams.

The focus is to give care teams a capacity layer that does not break when the eligible population grows. Care teams should remain responsible for the work that requires judgment, trust, and clinical interpretation: care planning, clinical review, complex patient conversations, escalations, practice-level decisions, relationship continuity, social and behavioral context, and exceptions that do not fit a standard path.

The smartest model is not "more automation" or "more people." It is human-led care with digital workers scaling the repeatable work around it.

Who owns which AWV step

A clear split of ownership is what lets the workflow grow without adding staff at the same rate. This is the division we recommend.

A Practical Operating Blueprint

ACOs can use a simple blueprint to build AWV capacity:

Step 1: Define the AWV population. Create a reliable list of eligible and overdue patients across practices.

Step 2: Segment intelligently. Separate patients by risk, gaps, prior engagement, language, practice relationship, and outreach difficulty.

Step 3: Standardize the message. Explain AWV as a prevention and care-planning visit, not a billing or compliance activity.

Step 4: Route outreach through the right channel. Use voice, SMS, and practice-based follow-up based on patient preference and response history.

Step 5: Prepare the visit. Surface only the most useful care context for the provider and practice team.

Step 6: Close the loop. Capture what happened, what needs follow-up, who owns the next step, and when it should be completed.

Step 7: Escalate intelligently. Route transportation barriers, confusion, clinical concerns, caregiver issues, and high-risk cases to the right human team.

This is how AWV becomes an operating model for preventive care, not just a visit count.

What ACOs Should Measure

The right metrics should cover the full workflow, not only outreach volume.

The most important measure is not whether the ACO "ran an AWV campaign." It is whether more patients received meaningful preventive care and whether the care team had the capacity to follow through.

The First Layer of Scalable Care Capacity

AWV is the right starting point because it is proactive, structured, measurable, and patient-centered. It helps ACOs build care capacity before the patient reaches a crisis point. It supports quality before gaps become performance issues. It gives the care team a better way to stay connected to patients who may otherwise drift until something goes wrong.

For ACOs, the next advantage will not come from simply knowing who is overdue. It will come from building the capacity to reach those patients, explain the value, schedule the visit, prepare the practice, complete the follow-up, and keep the relationship active. That is where AI digital workforce becomes powerful. Not as a replacement for care teams. As the scalable support layer around them.

At Zynix AI, we believe the next phase of accountable care will be built around human-led teams supported by digital workers that keep repeatable care workflows moving. Annual Wellness Visits are one of the best places to start.

If your ACO wants to improve AWV completion, patient engagement, care gap follow-through, and shared savings readiness, Zynix AI can help you build scalable AWV capacity around your existing care teams.

Frequently asked questions

How can an ACO increase its Annual Wellness Visit completion rate?

Run the AWV as a year-round workflow instead of a seasonal campaign. Keep one eligibility list that shows who is overdue and which practice owns each patient, rank outreach with risk and care-gap analytics that feed staff worklists, explain it as a prevention-planning visit rather than a routine physical, book it during the outreach conversation, and recover missed visits with two-way reminders and no-show follow-up. Give every post-visit task a named owner.

Why do Annual Wellness Visits matter for ACO shared savings?

In the Medicare Shared Savings Program, an ACO may share in the savings it achieves when it both delivers high-quality care and spends health care dollars more wisely. The AWV supports both: it updates each patient's prevention plan, brings due screenings and vaccines into view, surfaces risks such as medication problems or falls, and reconnects patients who have drifted from the practice. The same discipline carries over to an ACO's TCM and HCC gap programs.

Which patients belong on an ACO's AWV eligibility list?

Attributed patients with Medicare Part B who have not had a yearly wellness visit in the last 12 months. Medicare covers the visit once every 12 months, and a patient's first one cannot take place within 12 months of enrolling in Part B or of the "Welcome to Medicare" preventive visit. A working list also shows who is overdue, who was seen recently and which practice owns the relationship, so each patient hears from the right practice.

Which AWV tasks can AI agents handle, and what stays with the care team?

Agents suit the high-volume, rules-based steps: refreshing eligibility worklists, voice and SMS outreach, explaining the visit, booking and reminders, following up on missed appointments, logging every attempt and creating tasks after the visit. Care planning, clinical review, complex conversations and exceptions stay with the care team, and agents route clinical concerns and access barriers to staff by rule. In the Zynix platform, care plans for wellness visits sequence both sets of tasks and close only when each step is documented.

Will Medicare’s 12-month rule for Annual Wellness Visits change?

Not yet. As of November 2026, Medicare still covers the AWV once every 12 months. In its LEAD Model Request for Applications, CMS lists calendar-year AWV flexibility among benefit enhancements it may explore for future performance years, because ACOs report the 12-month rule is hard to track. Until CMS adopts it, build due lists on the 12-month rule; our AWV billing guide lists the required elements.

Related reading

• AWV Billing: G0438 vs G0439, Required Elements and Eligibility for 2026
• How To Improve AWV Completion Rates With AI-Powered Outreach
• HCC V28 Changes Explained: V24 vs V28 and What Applies in 2026 and 2027

Source notes

Medicare.gov: Yearly "Wellness" visits. https://www.medicare.gov/coverage/yearly-wellness-visits

CMS: Medicare Shared Savings Program. https://www.cms.gov/medicare/payment/shared-savings-program

CMS: Long-term Enhanced ACO Design (LEAD) Model, Request for Applications (revised April 15, 2026). https://www.cms.gov/priorities/innovation/files/lead-rfa.pdf

About the author

Jay Chowdappa, MD is co-founder and CEO of Zynix AI. He is a physician, and ACOs led by him generated $300M+ in shared savings before he started Zynix AI to help care teams follow through on what their data already shows.