Care Gap Closure as a Revenue Strategy: AWV, CCM, and the $340K Opportunity

The Three Revenue Streams in Care Gap Closure

Care gap revenue falls into three categories with meaningfully different risk profiles and billing mechanics: the Annual Wellness Visit (AWV), Chronic Care Management (CCM), and value-based contract performance payments tied to HEDIS measures. Each is distinct in how it is triggered, how it is billed, and how it is tracked — but all three share a common upstream requirement: you need to know which patients have open gaps before you can close them.

Annual Wellness Visit: The $180–$220 Opportunity Nobody Schedules

The Annual Wellness Visit (AWV) was introduced under the Affordable Care Act in 2011 and is covered at 100% under Medicare Part B — no copay, no deductible. CMS created it specifically to increase the rate of preventive care coordination in the Medicare population. More than a decade later, utilization remains low.

The 2025 Medicare non-facility reimbursement rates:

The AWV requires a health risk assessment, a personalized prevention plan, a review of the patient's current providers and suppliers, a cognitive impairment detection assessment, and a written 5–10 year screening schedule. It does not require a physical examination in the traditional sense — and it does not require the presence of the physician. Advanced practice providers, PAs, and even licensed clinical social workers can perform AWVs, which allows practices to run AWV clinics using non-physician staff and bill at these rates with appropriate supervision.

Chronic Care Management: $62–$84/Month Per Qualifying Patient

Chronic Care Management (CCM) was introduced in 2015 under CPT 99490 and has been expanded significantly since. It reimburses for non-face-to-face care coordination services provided to Medicare patients with two or more chronic conditions expected to last at least 12 months or until death, where the conditions place the patient at significant risk of death, acute exacerbation, functional decline, or functional impairment.

The qualifying population is enormous. In a typical primary care or internal medicine panel, 60–75% of Medicare patients have two or more qualifying chronic conditions. The 2025 Medicare CCM reimbursement structure:

To bill 99490, the practice must: (1) obtain written patient consent; (2) maintain a comprehensive electronic care plan accessible to all treating practitioners; (3) provide 24/7 access to care management via phone; and (4) document at least 20 minutes of clinical staff time per calendar month spent on care coordination activities. Clinical staff means nurses, medical assistants, or other supervised staff — not just physicians.

HEDIS Measures and Value-Based Contract Performance

The Healthcare Effectiveness Data and Information Set (HEDIS) is developed and maintained by NCQA and comprises over 90 measures across six domains. For practices participating in value-based contracts — Medicare Advantage shared savings, commercial ACO contracts, or Medicaid managed care agreements — HEDIS performance directly determines financial outcomes. The mechanism varies by contract type, but the most common structures include:

• Shared savings distributions: ACOs and primary care capitation models distribute surplus based on quality scores, often weighted at 30–50% of total payout
• Quality bonuses: MA plans pay per-member-per-month bonuses for hitting Star Rating thresholds, which are driven by HEDIS performance
• Risk corridor adjustments: Downside-risk models penalize for quality failures including unplanned readmissions, preventable ED visits, and care gap rates

The HEDIS measures most directly affected by primary care gap closure include: Controlling High Blood Pressure (CBP), Comprehensive Diabetes Care (CDC), Colorectal Cancer Screening (COL), Breast Cancer Screening (BCS), Adult Immunization Status (AIS), Medication Adherence for Cholesterol (MAC), and Preventive Care and Screening for Tobacco Use (TOB). A practice that moves from the 25th percentile to the 75th percentile on these measures — a realistic achievement with systematic outreach — commonly sees contract bonus payments increase by $40–$90 per attributed member per year.

The $340K Average: How It Builds

The $340,000 figure is not an optimistic projection — it is a conservative mid-case estimate derived from aggregating three revenue streams for a 5-provider practice with a typical Medicare and value-based payer mix:

Why the Gap Persists: A Data Problem, Not a Clinical Problem

The barrier to closing care gaps is not clinical capacity or provider willingness. The barrier is identification. To enroll patients in CCM, you need a list of patients with two or more qualifying chronic conditions who are not currently enrolled. To schedule AWVs, you need a list of eligible patients who have not had one in the past 12 months. To improve HEDIS performance, you need to know which members have open gaps across each measure.

In most EHR systems, generating these lists requires custom reports that either do not exist out of the box, require IT involvement to build, or are available only through expensive vendor analytics modules. The practical result is that care managers and care coordinators work from incomplete lists — or no lists at all — and outreach is reactive rather than systematic.

Vizier connects to your claims data and clinical data, builds the gap registry automatically, and surfaces the highest-priority patients for each intervention. AWV-eligible patients are ranked by time since last visit and chronic condition burden. CCM candidates are identified by diagnosis codes, sorted by estimated revenue per enrollment, and matched to care coordinator capacity. HEDIS gaps are updated monthly as claims adjudicate.