How To Improve AWV Completion Rates With AI-Powered Outreach

By Jay Chowdappa, MD, co-founder and CEO, Zynix AI · Updated October 30, 2026

Key takeaways

ACOs improve Annual Wellness Visit (AWV) completion rates by working a due list built from Medicare’s 12-month rule, ranking patients by open gaps and risk, explaining the no-cost visit in one sentence, booking it in the same conversation, offering telehealth and a pre-visit health risk assessment, rebooking no-shows within days and tracking completion weekly against a baseline.

Medicare Part B covers the yearly wellness visit once every 12 months at no cost to the patient when the provider accepts assignment, and CMS pays it as G0438 for the first visit and G0439 for later ones.
Explaining that the visit is a prevention-planning conversation, not a routine physical, removes a common source of confusion.
Barrier-aware scheduling offers telehealth, different times or community resources when transportation, caregivers or language get in the way.
Agents handle identification, outreach, booking and reminders, while clinicians run the visit and own every clinical question and the prevention plan.
Measure scheduled and completed visits, no-shows and staff outreach time against a baseline taken before you start.

Why AWV Completion Rates Matter for ACOs

Annual Wellness Visits are a core preventive care activity for Medicare beneficiaries, yet many ACOs struggle to complete one for every eligible patient. Each missed AWV represents lost revenue, undetected conditions, and unclosed HCC gaps. For an ACO with a large attributed population, improving AWV completion can translate into meaningful additional shared savings.

The Three Barriers to AWV Completion

1. Patient awareness: Many Medicare beneficiaries don't know they're eligible for an AWV, confuse it with a regular checkup, or don't understand the value. Traditional mailers get few responses.

2. Scheduling friction: Even motivated patients face barriers: transportation, caregiver availability, language differences, and difficulty navigating phone trees. Each barrier lowers the chance that an outreach conversation ends in a booked visit.

3. Staff capacity: Care coordinators managing large panels can't make enough outreach calls. The math doesn't work with manual workflows.

How AI Outreach Agents Transform AWV Completion

AI-powered outreach agents address all three barriers at once. Here's how the workflow operates:

Step 1: Intelligent patient identification. AI analyzes claims data, eligibility files, and visit history to identify every patient due for an AWV. It prioritizes by risk score, gap count, and likelihood of engagement.

Step 2: Multi-channel outreach. The AI agent initiates contact via the patient's preferred channel — phone call or SMS. Calls are conducted in the patient's preferred language with culturally appropriate scripts.

Step 3: Barrier-aware scheduling. When the agent identifies barriers (no transportation, caregiver conflicts, language needs), it adapts during the conversation — offering telehealth alternatives, suggesting different times, or connecting to community resources.

Step 4: Automated confirmation and reminders. Once scheduled, the system sends confirmation, 72-hour reminders, and day-of reminders. Reminders give patients a chance to reschedule before a missed visit instead of after it.

Real-World Results

Organizations that add AI-powered outreach to an AWV program usually track three things: scheduling rates, no-shows for scheduled visits and staff time spent on outreach. Results depend on the population, the quality of the eligibility data and how visit slots are staffed, so measure them against your own baseline. The Palm Beach ACO customer story describes how one ACO runs annual wellness visit outreach by voice and SMS across its provider network.

Getting Started

The fastest path to improved AWV completion starts with three steps: integrate your eligibility and claims data, configure outreach protocols for your patient population, and deploy AI agents alongside your existing care team. Set a baseline before you start so you can see the change in scheduled and completed visits.

What to tell patients about the visit

Many patients skip the Annual Wellness Visit because they do not know what it is. Outreach works better when it explains the visit in plain terms that match Medicare's own description.

Medicare Part B covers a yearly wellness visit once every 12 months, and the patient pays nothing if the provider accepts assignment. It is a conversation-based visit to create or update a personalized prevention plan, not a routine physical exam. The patient fills out a health risk assessment, and the provider takes routine measurements, reviews medical history and current prescriptions, performs a cognitive assessment and gives a written plan of the screenings, vaccines and other preventive services the patient needs. A patient's first yearly wellness visit cannot take place within 12 months of Part B enrollment or of the "Welcome to Medicare" preventive visit.

Scripts should make two points clearly. The visit focuses on prevention, so a specific health concern belongs in a separate appointment. And if the provider performs additional tests or services during the same visit that the wellness benefit does not cover, coinsurance and the Part B deductible may apply. Say both in the patient's preferred language.

Where the care team stays in charge

Outreach agents can find, contact, book and remind; the visit itself and every clinical question belong to the care team.

Agents work the eligibility list, explain the visit, book it, send reminders and follow up on missed appointments, within the rules and hours the practice sets. When a patient raises a symptom, a medication problem or a question about their health during outreach, the agent routes it to the care team by rule instead of answering it. The clinician conducts the visit, reviews the health risk assessment and agrees the prevention plan with the patient.

After the visit, the screenings, referrals and vaccines in the prevention plan become tasks with named owners, so the visit leads to completed care rather than a list. Care plans for wellness visits can sequence those agent and staff steps and close only when each step is documented.

How to improve AWV completion rates: strategies for ACOs

The ACOs that complete the most wellness visits treat the AWV as a year-round workflow with a due list, an outreach cadence and a weekly measure. Each strategy below starts with the action to take.

Build the due list from the 12-month rule. List every attributed patient whose last wellness visit was 12 or more months ago. CMS pays G0438 for a patient's first AWV and G0439 for each later one, only once in a 12-month period, and not within 12 months of a "Welcome to Medicare" preventive visit (G0402). Use claims history to find the date each patient becomes eligible, so outreach never books a visit Medicare will deny.
Rank who to reach first. Start with patients who have open care gaps, rising risk or no visit with their primary care practice in the past year, because the visit matters most for them. A population-level view of who is due and why keeps the list current as claims and ADT data arrive.
Explain the visit in one sentence. Tell patients it is a no-cost conversation with their own clinician to plan screenings and vaccines for the year, not a physical exam. Medicare says the patient pays nothing when the provider accepts assignment and the Part B deductible does not apply, though extra services in the same visit may cost something.
Book the visit in the same conversation. Offer two or three specific times instead of asking the patient to call back. Each callback is another chance for the visit not to happen.
Offer telehealth when travel is the barrier. CMS pays for G0438 and G0439 furnished by telehealth, so a video visit can reach patients who cannot get a ride or a caregiver for an office visit. Through December 31, 2027, Medicare patients can receive telehealth services anywhere in the United States, including at home; from January 1, 2028, most non-behavioral telehealth again generally requires the patient to be in a medical facility in a rural area.
Collect the health risk assessment before the visit. CMS allows the practice or the patient to update the health risk assessment before or during the AWV. Sending it ahead, or having staff complete it by phone, shortens the visit and gives the clinician the patient's answers in advance.
Remind, then rebook no-shows within days. Send a confirmation and reminders before the visit, and offer a new time on the day a patient misses one. A missed AWV recovered within the week is worth more than one rescheduled next quarter.
Turn the prevention plan into tasks. The visit produces a written list of screenings, vaccines and referrals. Give each item an owner and a due date in your care management workflow, so the AWV leads to completed care and closed quality gaps.
Measure weekly against a baseline. Track patients due, reached, scheduled, completed and no-show by site and clinician. Weekly numbers show which step is leaking while there is still time in the year to fix it.

Frequently asked questions

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

Start with a clean list of attributed patients who are due, ranked by risk and open gaps. Reach each patient in the channel they answer, explain the no-cost prevention-planning visit, book it in the same conversation, solve transportation or caregiver barriers on the spot and send reminders. Recover missed appointments within days, and keep clinicians in charge of the visit and prevention plan, as strong ACO wellness visit programs do.

Who is eligible for a Medicare Annual Wellness Visit?

People with Medicare Part B are covered for a yearly wellness visit once every 12 months. The first one cannot take place within 12 months of enrolling in Part B or of the "Welcome to Medicare" preventive visit, although a patient does not need to have had that visit to qualify. If the provider accepts assignment, the patient pays nothing for the wellness visit itself.

What are the billing codes for the Medicare Annual Wellness Visit?

CMS uses HCPCS G0438 for a patient's first Annual Wellness Visit and G0439 for each subsequent one. Either can be billed only once in a 12-month period, and not within 12 months of the "Welcome to Medicare" preventive visit, G0402. CMS also pays for both codes when the visit is furnished by telehealth. Federally qualified health centers use G0468 for a visit that includes an AWV. Our AWV billing guide lists the required elements.

Can a patient have an AWV once per calendar year instead of every 12 months?

Not under current Medicare coverage, which allows one yearly wellness visit every 12 months. ACOs have told CMS that the 12-month rule creates tracking and reporting burden, and CMS lists calendar-year AWV timing as a benefit enhancement under consideration for the LEAD Model, which starts in 2027. Until such a change is final, schedule each patient's next visit for when they are eligible again under the 12-month rule.

Can the Medicare Annual Wellness Visit be done by telehealth?

Yes. CMS pays for G0438 and G0439 when the visit is furnished by telehealth. Through December 31, 2027, Medicare patients can receive telehealth services anywhere in the United States, including at home. From January 1, 2028, non-behavioral telehealth generally requires the patient to be in a medical facility in a rural area again, so ACOs relying on home video wellness visits should plan in-person capacity for 2028.

Source notes

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

CMS: Annual Wellness Visit (Medicare preventive services, AWV coding, diagnosis and billing). https://www.cms.gov/medicare/coverage/preventive-services/medicare-wellness-visits/annual-wellness-visit

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

CMS: Telehealth FAQ (updated October 9, 2026). https://www.cms.gov/files/document/telehealth-faq-updated-10-09-2026.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.