Every Unfilled Care Gap Is Both a Clinical and Financial Failure
Care gap analysis serves two purposes simultaneously: it ensures patients receive evidence-based preventive care they are entitled to, and it captures the legitimate reimbursement attached to that care. Vizier calculates both dimensions — the clinical gap rate and the dollar value sitting uncaptured in your panel.
For a primary care practice with 2,000 Medicare patients, the combined uncaptured revenue from missed AWVs, depression screenings, colorectal screenings, mammography referrals, and CCM enrollment typically exceeds $400,000 annually. Vizier surfaces this by patient, by service, and by gap age — so your care team knows exactly who to call next.
HEDIS measure alignment is built in. Every care gap tracked by Vizier maps to its corresponding HEDIS measure — ensuring that closing revenue gaps simultaneously improves your quality scores for Medicare Advantage star ratings and value-based contracts.
Every Preventive Service Mapped to Revenue and Quality Measures
Annual Wellness Visit (AWV)
G0438 = first AWV, G0439 = subsequent. Requires Health Risk Assessment, updated preventive care plan, cognitive impairment screening. Often missed because 'physical' ≠ AWV.
Depression Screening
Annual PHQ-9 administration for Medicare patients. Frequently left unbilled when performed during AWV as a component rather than coded separately when done in a qualifying visit.
Diabetes Eye Exam
HEDIS CDC measure. Patients with diabetes should receive annual dilated eye exam. High care gap rate in primary care panels — typically requires referral tracking.
Colorectal Cancer Screening
Colonoscopy (45378) or Cologuard (81528, G0464). Ages 45–75. Total encounter value includes the procedure and anesthesia when applicable. HEDIS COL measure.
Tobacco Cessation Counseling
99406 = 3–10 minutes intermediate counseling, 99407 = >10 minutes intensive counseling. Medicare covers up to 8 sessions per year. Often documented but not billed.
Mammography Screening
Annual mammography for women 40+. Total encounter value includes imaging, radiologist interpretation, and any follow-up. HEDIS BCS measure. Referral tracking required.
Chronic Care Management (CCM)
For patients with 2+ chronic conditions. 20 minutes of clinical staff care management per month. Often the largest single uncaptured revenue opportunity in primary care.
Advance Care Planning
Voluntary discussion of advance directives. Medicare covers once per year. Frequently appropriate for patients 70+ with multiple comorbidities — rarely proactively scheduled.
The Medicare Annual Wellness Visit Is Not a Physical Exam
The most common AWV documentation error is confusing it with a comprehensive physical exam. The Medicare Annual Wellness Visit (G0438 for the first visit, G0439 for subsequent years) focuses on health risk assessment, preventive care planning, cognitive assessment, depression screening, and establishing a written advance care plan — not a head-to-toe physical examination.
Patients are eligible for their first AWV after being enrolled in Medicare Part B for at least 12 months, and have not received an Initial Preventive Physical Examination (IPPE, G0402) within the past 12 months. The AWV is covered 100% by Medicare Part B with no patient cost-sharing.
Vizier flags every Medicare patient who is AWV-eligible but has not been scheduled, sorted by time since last AWV and comorbidity burden — prioritizing patients where the preventive visit would generate the most clinical value and the highest care gap closure rate.
USPSTF Grade A and B Recommendations Vizier Monitors
USPSTF Grade A and B recommendations are covered without cost-sharing under ACA §2713 and feed multiple HEDIS and MIPS measures. Vizier tracks eligibility, screening status, and outreach priority for every Grade A/B recommendation applicable to your panel.
Colorectal Cancer Screening
Grade ABreast Cancer Screening
Grade BCervical Cancer Screening
Grade ALung Cancer Screening
Grade BHypertension Screening
Grade AType 2 Diabetes / Prediabetes Screening
Grade BStatin Therapy for CVD Prevention
Grade BTobacco Cessation Counseling
Grade ADepression Screening
Grade BUnhealthy Alcohol Use Screening
Grade BObesity — Behavioral Counseling
Grade BHepatitis C Screening
Grade BHIV Screening
Grade AOsteoporosis Screening
Grade BAbdominal Aortic Aneurysm Screening
Grade BPrEP for HIV Prevention
Grade AVizier refreshes the recommendation set automatically as USPSTF publishes updates. Grade D recommendations (no benefit / harms outweigh benefits) and Grade I (insufficient evidence) are tracked separately so that contraindicated services do not appear in care gap worklists.
How care gap data gets into Vizier
Direct EHR connector pulls problem lists and screening history. Scheduled feed handles claims-based gap detection. Upload Medicare roster CSVs for ad-hoc panel sweeps.
Connect Vizier directly to your EHR via FHIR R4 or HL7 v2 and pull Patient, Condition, Procedure, Observation, MeasureReport, CarePlan resources for AWV / CCM / TCM / cancer-screening gap identification on a schedule or on demand. Live for Epic, Cerner / Oracle Health, AthenaHealth, Allscripts / Veradigm, MEDITECH, SystmOne, EMIS, NextGen, eClinicalWorks. OAuth 2.0 / SMART on FHIR, read-only, BAA executed before any PHI flows.
Your existing reporting environment writes CSV to SFTP or secure cloud storage. Vizier picks it up. Most common path for organizations with internal data warehouses or restricted external API access.
When you need the answer this hour. Ad-hoc analysis, data outside your EHR (payer files, registry exports, survey data), or proof-of-value before IT approves a connector.
FAQ
Care Gap Analytics — Frequently Asked Questions
Which care gaps does Vizier identify?+
All the high-revenue, audit-defensible gaps: Annual Wellness Visits (G0438 / G0439), Chronic Care Management eligibility (CPT 99490 / 99491 / 99437 / 99439), Transitional Care Management (99495 / 99496), Behavioral Health Integration (99492 / 99493 / 99494), Principal Care Management (99424 / 99425), USPSTF cancer screenings (colorectal, breast, cervical, lung), HEDIS care gaps (diabetes A1C, BP control, statin therapy, depression screening), and immunization gaps. Each gap is dollar-quantified.
How does Vizier calculate AWV eligibility?+
For each Medicare beneficiary in the panel, Vizier checks: (1) is the patient enrolled in Medicare Part B for at least 12 months, (2) has there been an Initial AWV (G0438) yet, (3) if yes, has 12+ months passed since the last AWV. Eligible-and-unscheduled patients are sorted by days-overdue so outreach prioritizes the highest-recovery cohort first.
Can Vizier match CCM-eligible patients to billable encounters?+
Yes. CCM eligibility requires two or more chronic conditions expected to last at least 12 months. Vizier identifies eligible patients from the problem list, tracks documented care plan and 24/7 access requirements, and surfaces the gap between eligible and billed each month. Most practices bill CCM on under 30% of eligible patients — the recovery is meaningful.
Does Vizier integrate with our outreach workflow (calls, secure messages)?+
Vizier produces the prioritized worklist; outreach happens in your existing system (EHR portal, dialer, secure messaging platform). The list exports to CSV or pushes via webhook to common CRM and outreach tools. Closed gaps flow back automatically the next time data refreshes from the EHR connector.
What's the typical revenue recovery from a care gap program?+
Industry-typical: $300K-$600K annually for a 5-provider primary care practice with average baseline gap closure rates moving to top-quartile. The single highest-leverage gap is usually AWV (~$300K alone); CCM and TCM stack additional value. The recovery is operational, not clinical — the analytics surfaces work that's already being done but not consistently billed.
How does Vizier handle SDOH-influenced gaps?+
Where SDOH screening data is available (PRAPARE, Z-codes, or external SDOH feeds), Vizier joins it to gap closure analytics. A patient with a transportation barrier and a missed AWV is a different intervention than the same patient without that barrier — the workflow can route appropriately.
How Much Revenue Is in Your Patient Panel?
Upload your patient roster and Medicare eligibility data. Vizier calculates the total care gap revenue available in your panel, ranked by gap type, patient priority, and estimated reimbursement.