HHS-OIG Audit A-02-22-01018 — Seventeen of Twenty-Five Hospitals Violated PRF Balance Billing Requirement (September 2025)

Record facts

Full text

OIG.HHS.GOV 
September 2025| A-02-22-01018 
 
Seventeen of Twenty-Five Selected 
Hospitals Did Not Comply or  
May Not Have Complied With the 
Provider Relief Fund Balance Billing 
Requirement 
 

 
OIG.HHS.GOV 
 
September 2025 | A-02-22-01018 
Seventeen of Twenty-Five Selected Hospitals Did Not Comply or May 
Not Have Complied With the Provider Relief Fund Balance Billing 
Requirement  
Why OIG Did This Audit  
• Congress appropriated $178 billion to HHS to provide funds to eligible providers for health care-related 
expenses or lost revenue attributable to COVID-19 under the Provider Relief Fund (PRF) program.  
HHS was responsible for initial PRF program oversight and policy decisions, and HRSA administered the 
PRF program.   
• Under the PRF terms and conditions, if a patient had health insurance and sought COVID-19 treatment 
from an out-of-network provider that received PRF payments, the provider would not seek to collect 
out-of-pocket payments greater than what the patient would have otherwise been required to pay if 
the care had been provided by an in-network provider.  (We refer to this as the “balance billing 
requirement.”) 
• This audit assessed whether selected hospitals that received PRF payments complied with the balance 
billing requirement for COVID-19 inpatients. 
What OIG Found 
• Of the 25 selected hospitals, 17 billed patients an amount that did not comply or may not have 
complied with the balance billing requirement.  For example, one hospital billed a patient $6,000 
when the patient’s insurance carrier had waived all patient cost-sharing responsibility. 
• Hospitals stated that they were uncertain how to comply with the requirement because HRSA did not 
provide sufficient guidance.  If HRSA developed and provided early and detailed guidance, hospitals 
might not have improperly billed selected patients a total of $637,035 for services provided. 
What OIG Recommends 
We made two recommendations to HRSA, including that it determine whether the selected hospitals made 
refunds to patients identified in this audit for billings that did not or may not have complied with the balance 
billing requirement and perform postpayment reviews of hospitals for compliance with the balance billing 
requirement as part of its ongoing program integrity procedures.  The full recommendations are in the report. 
HRSA concurred with both recommendations and described actions that it plans to take in response to the 
recommendations. 

 
Hospitals’ Compliance with Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
 
TABLE OF CONTENTS 
 
INTRODUCTION ............................................................................................................................... 1 
 
Why We Did This Audit ....................................................................................................... 1 
 
Objective ............................................................................................................................. 2 
 
Background ......................................................................................................................... 2 
The Provider Relief Fund ......................................................................................... 2 
HHS’s and HRSA’s Oversight of the Provider Relief Fund Program ........................ 2 
Requirements for Hospitals That Received Provider Relief Fund Payments .......... 3 
 
 
Hospitals’ Compliance With Provider Relief Fund Patient Balance  
Billing Requirement ................................................................................................ 4 
 
How We Conducted This Audit ........................................................................................... 5 
 
FINDINGS ......................................................................................................................................... 6 
 
Hospitals Did Not Comply With the Balance Billing Requirement When Billing Some 
   Out-of-Network COVID-19 Patients ................................................................................. 7 
 
Hospitals May Not Have Complied With the Balance Billing Requirement When Billing 
   Some Out-of-Network COVID-19 Patients ....................................................................... 8 
 
Causes for Improper and Potentially Improper Patient Billings ......................................... 9 
 
RECOMMENDATIONS ................................................................................................................... 10 
 
HRSA COMMENTS ......................................................................................................................... 10 
 
APPENDICES 
 
A: Audit Scope and Methodology ..................................................................................... 11 
 
B: Related Office of Inspector General Reports ................................................................ 15 
 
C: Summary of Findings .................................................................................................... 16 
 
D: HRSA Comments ........................................................................................................... 21 
 
 
 

 
Hospitals’ Compliance With Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
1 
INTRODUCTION 
 
WHY WE DID THIS AUDIT 
 
The Provider Relief Fund (PRF) program provided funds to eligible hospitals and other health 
care providers (collectively referred to as “providers”) for: (1) health care-related expenses or 
lost revenues (e.g., due to canceled elective services) attributable to COVID-19, (2) COVID-19 
testing and treatment for uninsured individuals, and (3) the administration of COVID-19 
vaccines.  Federal laws appropriated to HHS a combined $178 billion in funds, which were, in 
part, distributed as direct payments to providers in a series of PRF General and Targeted 
Distributions.1, 2, 3 
 
This audit assessed selected hospitals’ compliance with PRF terms and conditions barring 
hospitals from seeking to collect out-of-pocket payments from COVID-19 inpatients (patients) 
greater than what the patients would have otherwise been required to pay if their care had 
been provided by an in-network hospital.4  (We refer to this as the “balance billing 
requirement” throughout the report.)  It is one of several Office of Inspector General (OIG) 
audits of various aspects of PRF payments, including: (1) the Department of Health and Human 
Services’ (HHS’s) and the Health Resources and Services Administration’s (HRSA’s) controls 
related to the requirements for submitting revenue information and attesting to the 
acceptance or rejection of PRF payments, (2) HHS’s and HRSA’s controls over PRF payment 
calculations and provider eligibility determinations, (3) claims for COVID-19 testing and 
treatment services for uninsured individuals, and (4) whether selected providers complied with 
terms and conditions and Federal requirements for expending PRF funds.  See Appendix B for a 
list of related OIG reports.  
 
 
1 The Coronavirus Aid, Relief, and Economic Security Act, P.L. No. 116-136, signed into law on Mar. 27, 2020, 
appropriated $100 billion; the Paycheck Protection Program and Health Care Enhancement Act, P.L. No. 116-139, 
signed into law on Apr. 24, 2020, appropriated $75 billion; and the Consolidated Appropriations Act, 2021, 
P.L. No. 116-260, signed into law on Dec. 27, 2020, appropriated $3 billion. 
 
2 Under the General Distributions, PRF payments were distributed in four phases (Phases 1, 2, 3, and 4), and within 
each phase, a wave number was assigned to a group of payments based on the payment distribution date.  For 
example, under the Phase 1 General Distribution, PRF payments were distributed to eligible Medicare providers 
that billed Medicare fee-for-service (Medicare Parts A or B) in calendar year (CY) 2019.  Under the Targeted 
Distributions, PRF payments were made to providers to address added COVID-19 challenges, such as high-need 
and vulnerable populations, including nursing homes and providers serving individuals in rural areas and safety net 
hospitals. 
 
3 In June 2023, with the passage of the Fiscal Responsibility Act of 2023, P.L. No. 118-5, Congress rescinded some 
unobligated PRF funds.  In response, HRSA stopped making PRF payments to providers. 
 
4 In-network providers have contractual agreements with a patient’s insurance carrier (carrier) and accept 
negotiated rates for services.  Conversely, out-of-network providers do not have a contractual agreement with an 
individual’s carrier and typically charge more for services than in-network providers. 

 
Hospitals’ Compliance With Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
2 
OBJECTIVE 
 
Our objective was to determine whether selected hospitals that received PRF payments 
complied with the PRF balance billing requirement for COVID-19 inpatients. 
 
BACKGROUND 
 
The Provider Relief Fund 
 
On January 30, 2020, the World Health Organization declared the COVID-19 outbreak a public 
health emergency of international concern, and on March 11, 2020, it characterized COVID-19 
as a pandemic.  Then, on March 13, 2020, the President declared the COVID-19 outbreak a 
national emergency.5   
 
The PRF was established to provide funds to eligible providers for: (1) health care-related 
expenses or lost revenues attributable to COVID-19, (2) COVID-19 testing and treatment for 
uninsured individuals, and (3) the administration of vaccines to the uninsured and 
underinsured.6  Congress appropriated a combined $178 billion in funding from the Coronavirus 
Aid, Relief, and Economic Security Act; the Paycheck Protection Program and Health Care 
Enhancement Act; and the Consolidated Appropriations Act, 2021, of which $145.9 billion was 
distributed to providers for health care-related expenses attributable to COVID-19.7 
 
HHS’s and HRSA’s Oversight of the Provider Relief Fund Program 
 
The HHS Office of the Secretary was responsible for initial PRF program oversight and policy 
decisions.  The HHS Office of the Secretary’s direct responsibility for the PRF program allowed 
HHS to meet its mission to expedite the establishment of the PRF and the distribution of funds 
as quickly as possible for providers’ health care-related expenses or lost revenues attributable 
to COVID-19.  Within HHS, HRSA was responsible for providing day-to-day oversight and 
managed all aspects of the PRF program.8   
 
 
5 The national emergency ended on May 11, 2023. 
 
6 According to HHS’s Instructions for the Distribution for Medicaid, CHIP, and Dental Providers Via Enhanced 
Provider Relief Fund Payment Portal, lost revenues attributable to COVID-19 means “the amount of any patient 
care revenue that you as a healthcare provider lost due to coronavirus, net of any increased revenues due to 
coronavirus (e.g., insurance reimbursed treatment).”  This revenue may include revenue losses associated with 
fewer outpatient visits or canceled elective procedures or services. 
 
7 Congress also appropriated $8.5 billion of COVID-19-related relief for rural providers enrolled in the Medicare or 
Medicaid programs (American Rescue Plan Act of 2021, P.L. No. 117-2).  This funding is administered by HRSA and 
has similar limitations and requirements as the PRF but is not part of the PRF. 
 
8 HHS and HRSA, PRF General & Targeted Distribution Cycle Memo, dated Sept. 30, 2020, and Sept. 30, 2021.   

 
Hospitals’ Compliance With Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
3 
HRSA provided various resources to providers on the proper use and reporting of 
PRF payments, including issuing a series of Frequently Asked Questions (FAQs), and guidance on 
the balance billing requirement.9  In addition, HRSA engaged external audit firms to conduct 
risk-based audits for a sample of providers to ensure that providers complied with PRF terms 
and conditions.  
 
Requirements for Hospitals That Received Provider Relief Fund Payments  
 
As a condition of receiving PRF payments, providers, including hospitals,10 agreed to the 
PRF terms and conditions.11  Under the terms and conditions, hospitals were required to 
comply with various requirements in order to retain and use PRF distribution payments.  One of 
these requirements stipulated that if a patient had insurance and sought treatment for actual 
or presumptive COVID-19 from an out-of-network hospital, the hospital would not seek to 
collect out-of-pocket payments greater than what the patient would have otherwise been 
required to pay if the care had been provided by an in-network hospital.12, 13  The balance 
billing requirement was included in the terms and conditions to ensure that COVID-19 patients 
would not incur financial hardships during the public health emergency because they may have 
been required to seek care from out-of-network hospitals due to capacity constraints at in-
network hospitals.14 
 
Due to the variation in in-network cost-sharing15 responsibility across insurance carriers 
(carriers) and benefit plans, HRSA established the Affordable Care Act (ACA) Marketplace out-
 
9 HRSA, “PRB Provider Relief Fund General Information FAQ.”  Accessed on Apr. 1, 2025.  We note that HRSA 
initially published this guidance on balance billing on May 6, 2020. 
 
10 PRF payments were distributed to providers based on providers’ Taxpayer Identification Numbers (TINs).  We 
use the term “hospital” to refer to a hospital reporting entity that registered its TIN through HRSA’s PRF Reporting 
Portal to report how it and its associated subsidiaries used PRF payments.  A hospital may be a stand-alone 
hospital, a hospital group, or a parent organization. 
 
11 Generally, providers were required to sign an attestation confirming receipt of PRF funds and agree to applicable 
terms and conditions within 90 days of receiving a PRF payment. 
 
12 HRSA, “Relief Fund Payment from $20 Billion General Distribution Terms and Conditions.”  Accessed on Apr. 1, 
2025. 
 
13 HRSA, Provider Relief Programs: Provider Relief Funds and ARP Rural Payments Frequently Asked Questions.  
Accessed on Apr. 1, 2025. 
 
14 The balance billing requirement is unrelated to the No Surprises Act of 2022, which was enacted to protect 
individuals from financial hardships that could result from large “surprise” medical bills. 
 
15 Cost-sharing is defined as the share of costs covered by an individual’s insurance that is paid by the patient.  This 
generally includes deductibles, co-insurance, and co-payments or similar charges but does not include insurance 
premiums, balance billing amounts for out-of-network providers, or the cost of noncovered services. 
 

 
Hospitals’ Compliance With Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
4 
of-pocket limitation16 as the generally expected threshold for assessing compliance with the 
balance billing requirement when an out-of-network patient’s in-network cost-sharing amount 
could not be determined.17   
 
Hospitals’ Compliance With Provider Relief Fund Patient Balance Billing Requirement  
 
Generally, as illustrated in Exhibit 1 (next page), compliance with the PRF balance billing 
requirement began when a patient was admitted to an out-of-network hospital with a 
presumptive or actual COVID-19 diagnosis.  The hospital should have prepared a claim for 
submission to the patient’s carrier based on the services provided during the patient’s stay.  
The carrier would process the hospital’s claim based on the patient’s insurance plan and issue a 
remittance statement, also known as an explanation of benefits (EOB) statement, to the 
hospital.  Generally, the EOB would identify what portion of the submitted claim was: 
(1) covered by the carrier, (2) the patient’s cost-share amount, and (3) the patient’s 
responsibility.18, 19  Upon receipt of the EOB, the hospital was required, through its acceptance 
of PRF funding, to first determine if the patient’s cost-share amount was based on the carrier’s 
in-network or out-of-network rate.  If the patient’s responsibility on the EOB was calculated 
based on the out-of-network rate, the hospital should not have billed the amount shown on the 
EOB.  Instead, the hospital should have attempted to identify the carrier’s in-network rate and 
then billed the patient for this verified amount.  If the hospital was unable to identify this 
amount, the ACA Marketplace out-of-pocket limitation would be the generally expected 
threshold for assessing compliance with the balance billing requirement. 
 
 
16 The ACA Marketplace out-of-pocket limit was $8,550 for an individual and $17,100 for a family for the 2021 plan 
year.  For the 2022 plan year, the limits were $8,700 and $17,400, respectively.  During our audit, HRSA stated that 
it established this threshold because out-of-pocket responsibility varied by plan and HRSA could not identify this 
information.  We note that HRSA described the ACA Marketplace out-of-pocket limitation as a compliance 
threshold as part of a technical update after our audit period on Apr. 6, 2022. 
 
17 HRSA, Provider Relief Programs: Provider Relief Funds and ARP Rural Payments Frequently Asked Questions.  
Accessed on Apr. 1, 2025. 
 
18 During the pandemic, many insurers waived—or temporarily waived—out-of-pocket costs for COVID-19 patients 
enrolled in fully insured plans.  For example, Aetna initiated a cost-sharing waiver for some private plans and 
Medicare Advantage plan members through Jan. 31, 2021, and Cigna initiated a waiver for all COVID-19 treatment 
through Feb. 15, 2021.  We refer to this as a “waiver” throughout the report.   
 
19 Patient responsibility is what the patient owes after the insurance payment to the hospital and patient’s 
cost-share amount are deducted. 

 
Hospitals’ Compliance With Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
5 
Exhibit 1: Example of Hospital Billing Process for Seeking 
Reimbursement of COVID-19 Inpatient Services 
 
 
 
For hospitals to have complied with the balance billing requirement, they would have issued 
bills to patients that could have been categorized in one of four ways: 
 
1. The hospital would not bill the patient or would bill the patient for zero dollars because 
the hospital waived the patient’s cost-share amount.   
 
2. The hospital would not bill the patient or would bill the patient for zero dollars because 
the carrier waived the patient’s cost-share amount. 
 
3. The hospital would bill the patient at the patient’s in-network cost-share amount. 
 
4. The hospital could not determine the patient’s in-network cost-share amount and would 
bill the patient up to the ACA Marketplace out-of-pocket limitation. 
 
HOW WE CONDUCTED THIS AUDIT 
 
We reviewed selected hospitals for compliance with the PRF balance billing requirement.  Our 
sample included hospitals associated with Taxpayer Identification Numbers (TINs) that kept a 

 
Hospitals’ Compliance With Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
6 
Wave 4 PRF distribution totaling $10,000 or more.20  From these hospitals, we selected for 
audit a nonstatistical sample of 25 hospitals (associated with 24 TINs) that admitted 4 or more 
out-of-network patients with either a positive COVID-19 test result or a COVID-19 diagnosis 
code.21  The hospitals were selected based on hospital type (e.g., critical access hospitals [CAHs] 
and long-term care hospitals), geographic location (i.e., rural or urban), organizational structure 
(i.e., hospital groups and stand-alone hospitals), and hospital bed count.22  For each hospital, 
we nonstatistically selected the hospital billing documentation for four of these patients based 
on the amount billed and type of insurance coverage (e.g., private health insurance or Medicare 
Part C).  Specifically, we reviewed hospital bills for treatment provided to 100 patients 
during 2 periods: (1) January 1, 2021, through March 31, 2021, and (2) January 1, 2022, through 
March 31, 2022 (audit period).23  We also reviewed HRSA’s balance billing guidance to 
providers and the selected hospitals’ policies and procedures for compliance with the balance 
billing requirement. 
 
We conducted this performance audit in accordance with generally accepted government 
auditing standards.  Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions 
based on our audit objectives.  We believe that the evidence obtained provides a reasonable 
basis for our findings and conclusions based on our audit objectives. 
 
Appendix A describes our audit scope and methodology. 
 
FINDINGS 
 
Of the 25 selected hospitals, 8 complied with the PRF balance billing requirement.  However, 
the remaining 17 hospitals did not comply or may not have complied with the balance billing 
requirement.  Specifically, 9 hospitals improperly billed 18 patients when patients’ carriers 
waived the patients’ cost-sharing responsibility, billed the patients’ carriers’ out-of-network 
rate instead of the required in-network rate, or billed at a rate above the ACA Marketplace out-
of-pocket limitation.  In addition, 13 hospitals billed 24 patients an amount that may not have 
complied with the requirement.  These hospitals did not confirm whether: (1) the billed amount 
was the patients’ in-network or out-of-network cost-sharing amount or (2) the patients’ carriers 
 
20 HRSA assigned wave numbers to payments under the General Distributions.  Wave 4 automatic PRF payments 
were part of the Phase 1 General Distribution and were dispersed on Apr. 24, 2020, by HRSA to providers based on 
revenue data from providers’ Medicare cost reports on file with the Centers for Medicare & Medicaid Services for 
fiscal years 2017 and 2018.  One or more hospitals may be associated with a single TIN. 
 
21 For this audit, two of the selected hospitals were associated with the same TIN. 
 
22 The selection factors were designed to cover various types and sizes of hospitals nationwide. 
 
23 We selected the two periods to compare and determine if any changes (e.g., expiration of an insurer’s waivers or 
updated HRSA guidance) impacted the sampled hospitals’ ability to comply with the balance billing requirement 
and did not identify any material differences in the hospitals’ compliance between the two periods. 

 
Hospitals’ Compliance With Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
7 
may have waived out-of-pocket costs for COVID-19 services.  The total number of hospitals 
exceeds 17 because we identified 5 hospitals with errors in both categories. 
 
These improper or potentially improper billings occurred because, according to the selected 
hospitals, they were uncertain of how to comply with the balance billing requirement due to a 
lack of sufficient guidance from HRSA.  For example, HRSA did not provide guidance on the ACA 
Marketplace out-of-pocket limitation as a compliance threshold until April 6, 2022—after our 
audit period.  If HRSA had developed and provided detailed guidance earlier and the selected 
hospitals had verified patients’ in-network rates, the hospitals might not have improperly billed 
the selected patients a total of $637,035 for services provided.  
 
Appendix C contains a summary of our findings by hospital and patient. 
 
HOSPITALS DID NOT COMPLY WITH THE BALANCE BILLING REQUIREMENT WHEN BILLING 
SOME OUT-OF-NETWORK COVID-19 PATIENTS 
 
The PRF terms and conditions required recipients to certify that they would not seek to collect 
out-of-pocket expenses from patients that exceeded what the patients would have otherwise 
been required to pay if their care had been provided by an in-network provider.24 
 
HRSA’s PRF FAQs stated that providers that accepted PRF payments should have submitted 
claims to patients’ carriers for COVID-19 services.  Providers could only seek out-of-pocket 
expenses from patients that were no greater than what the patient would have been required 
to pay if they were in-network patients.  HRSA stated that, generally, “it would be highly 
unusual for providers to collect” an amount from an out-of-network patient that exceeds the 
ACA Marketplace out-of-pocket limitation for the calendar year.25, 26 
 
Of the 25 selected hospitals, 9 hospitals did not comply with the balance billing requirement 
when billing out-of-network patients.  The hospitals improperly billed 18 patients a total of 
$601,585 for services provided.27  Specifically: 
 
 
24 HRSA, “Relief Fund Payment from $20 Billion General Distribution Terms and Conditions.”  Accessed on Apr. 1, 
2025. 
 
25 HRSA, Provider Relief Programs: Provider Relief Funds and ARP Rural Payments Frequently Asked Questions.  
Accessed on Apr. 1, 2025. 
 
26 This amount is the most an individual would pay for covered services in a plan year.  After this amount is spent 
on deductibles, co-payments, and co-insurance for in-network care and services, the health plan pays all allowable 
costs of covered benefits. 
 
27 The total number of hospitals and patients exceed 9 and 18, respectively, because some hospitals made multiple 
billing errors. 
 

 
Hospitals’ Compliance With Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
8 
• Seven hospitals billed nine patients a total of $488,926 for services provided despite the 
patients’ carriers having waived the patients’ cost-sharing responsibility.28  For example, 
one hospital billed a patient $6,000 for services provided; however, for the period in 
which the services were provided, the patient’s carrier waived all patient cost-sharing 
responsibility.  Accordingly, the hospital should not have billed the patient for the 
services. 
 
• Three hospitals billed eight patients a total of $11,628 for services provided at the 
patients’ carriers’ out-of-network rate instead of the required in-network rate.  For 
example, one hospital billed a patient more than $2,000 for services provided.  The 
hospital confirmed that the amount billed was the out-of-network rate for the patient’s 
carrier. 
 
• Two hospitals billed four patients for amounts that exceeded the ACA Marketplace out-
of-pocket limitation.  For three of these patients, the carrier had waived the patients’ 
cost-sharing responsibility, and the associated improperly billed amounts are included in 
the respective finding above.  For the remaining patient, the hospital billed the patient 
$101,031 in excess of the out-of-pocket limitation.29 
 
As a result, patients in our sample selection received improper hospital bills for services 
provided, totaling $601,585.  We noted that hospitals either: (1) collected payments from 
patients; (2) wrote off the bills, effectively canceling the debt; (3) classified the bills as 
outstanding and—as of the end of our fieldwork—continued efforts to collect payment; or 
(4) transferred the unpaid bills to collection agencies. 
 
HOSPITALS MAY NOT HAVE COMPLIED WITH THE BALANCE BILLING REQUIREMENT WHEN 
BILLING SOME OUT-OF-NETWORK COVID-19 PATIENTS  
 
The PRF terms and conditions required recipients to certify that they would not seek to collect 
out-of-pocket expenses from patients that exceeded what the patients would have otherwise 
been required to pay if their care had been provided by an in-network provider. 
 
Of the 25 selected hospitals, 13 hospitals may not have complied with the balance billing 
requirement when billing some out-of-network patients.  The hospitals billed 24 patients a total 
of $35,450 when the hospital did not confirm whether: (1) the billed amount was the patient’s 
 
28 Waiving the cost-sharing amount effectively made the patient’s in-network responsibility amount zero. 
 
29 For this patient, the hospital did not verify the patient’s in-network cost-sharing amount.  To be conservative, we 
used the highest ACA Marketplace out-of-pocket amount (i.e., $17,100 for the 2021 plan year) to determine the 
amount in which the billed amount, $118,131, exceeded the limitation.  

 
Hospitals’ Compliance With Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
9 
in-network or out-of-network cost-sharing amount or (2) the patient’s carrier may have waived 
out-of-pocket costs for COVID-19 services.30  Specifically: 
 
• Nine hospitals billed seventeen patients a total of $20,302 for services provided without 
confirming whether the patients were billed their in-network or out-of-network cost-
sharing amount.  We could not determine whether the hospitals complied with the 
balance billing requirement because hospital billing staff did not verify that the amount 
on the carrier’s EOB was based on the patient’s in-network or out-of-network cost-
sharing amount. 
 
• Six hospitals billed seven patients a total of $15,148 for services provided without 
confirming whether the patients’ carriers had waived out-of-pocket costs for COVID-19 
services.31  We could not determine whether a waiver was in place because this 
information was not readily available from the patients’ carriers.  For example, one 
patient’s carrier may have extended its COVID-19 waiver to cover the period the patient 
was admitted to the hospital.  We could not determine if such a waiver was in place 
because the carrier’s parent company allowed its individual plans to decide whether and 
how long such a waiver would be effective. 
 
These instances of potential noncompliance with the balance billing requirement resulted in 
patients in our sample selection receiving hospital bills totaling $35,450 that may have 
exceeded their in-network cost-sharing amount or waived out-of-network cost.  We noted that 
hospitals either: (1) collected payments from patients, some of which were subsequently 
refunded; (2) wrote off the bills, effectively canceling the debt; (3) classified the bills as 
outstanding and—as of the end of our fieldwork—continued efforts to collect payment; or 
(4) transferred the unpaid bills to collection agencies. 
 
CAUSES FOR IMPROPER AND POTENTIALLY IMPROPER PATIENT BILLINGS  
 
These improper or potentially improper billings occurred because, according to the selected 
hospitals, they were uncertain how to comply with the balance billing requirement due to a lack 
of sufficient guidance from HRSA.  The hospitals stated that they reviewed HRSA’s guidance and 
 
30 The total number of hospitals exceeds 13 because, for 2 hospitals, we could not determine whether there was a 
waiver in place and the hospital did not confirm whether the billed amount was the patient’s in-network or out-of-
network cost-sharing amount. 
 
31 This amount does not include one patient bill, totaling $1,100, because the hospital additionally did not confirm 
whether the patient was billed their in-network or out-of-network cost-sharing amount, and the billed amount was 
included in the total for that error category. 
 

 
Hospitals’ Compliance With Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
10 
FAQs; however, due to the limited nature of the guidance, some hospitals developed billing 
policies and procedures based on their own interpretations of the requirement.32 
 
HRSA’s operational objective at the beginning of the public health emergency was to ensure 
that individuals did not face severe economic hardship during the public health emergency.  In 
addition, the degree of difficulty in implementing and providing oversight over this 
requirement, intended to protect individuals, could not be anticipated.33 
 
RECOMMENDATIONS 
 
We recommend that the Health Resources and Services Administration: 
 
• determine whether the selected hospitals made refunds to the patients identified in this 
audit for billings that did not or may not have complied with the PRF balance billing 
requirement and 
 
• as part of its established and ongoing program integrity procedures, perform 
postpayment reviews of hospitals for compliance with the balance billing requirement, 
including the hospitals we identified that may not have complied, to ensure that 
patients were not billed more than their in-network amount and were refunded any 
improper billed amounts. 
 
HRSA COMMENTS 
 
In written comments on the draft report, HRSA concurred with both recommendations and 
described corrective actions it plans to address them, including reviewing the selected 
hospitals’ compliance with PRF balance billing requirements and requesting that the hospitals 
make refunds to patients, as appropriate. 
 
HRSA also provided technical comments on our draft report, which we addressed as 
appropriate.  HRSA’s comments, excluding the technical comments, are included as Appendix D. 
 
32 To prevent against noncompliance with the requirement, some hospitals made the independent decision to 
waive billing the patient for the balance of the claim not reimbursed by insurance. 
 
33 Key stakeholders and decisionmakers should use the information included in this report when determining 
lessons learned from administering PRF distributions during the COVID-19 national emergency. 

 
Hospitals’ Compliance With Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
11 
APPENDIX A: AUDIT SCOPE AND METHODOLOGY 
 
SCOPE 
 
Our audit covered a nonstatistical sample of 25 hospitals (associated with 24 TINs) that 
received and kept PRF payments during calendar year (CY) 2020, and from the 25 selected 
hospitals, we nonstatistically selected 100 out-of-network patients (4 from each hospital).34  
The hospitals were selected based on payment amount, geographic location, patient count, 
type of entity, and facility size.  The patients were selected based on billed amount and 
insurance type (e.g., private, Medicare Part C, or Medicaid).  The sample unit was a hospital 
entity associated with a reporting TIN35 that kept a Wave 4 PRF payment made on 
April 24, 2020, which was calculated using its submitted cost reports for fiscal years 2017 and 
2018.  We identified 6,010 hospitals associated with 5,316 TINs that received PRF payments 
during CY 2020.  From the 5,316 TINs, we identified the hospitals that kept Wave 4 PRF 
distributions totaling $10,000 or more and arrived at 3,414 hospitals associated with 
2,939 TINs.  We further refined the list based on the PRF payment amount,36 geographic 
locations (i.e., urban and rural areas), organizational structure (i.e., hospital groups and stand-
alone hospitals), and hospital bed count, leaving us with 265 hospitals associated with 
77 TINs.37  From this list of 265 hospitals, we selected our nonstatistical sample of 25 hospitals 
that admitted 4 or more out-of-network patients with either a positive COVID-19 test result or a 
COVID-19 diagnosis code. 
 
To determine the selected hospitals’ compliance with the PRF balance billing requirement, we 
reviewed hospital billing documentation maintained for the selected patients.  Specifically, we 
reviewed bills for treatment38 provided to the selected 100 patients during 2 periods: 
 
34 PRF payment recipients had 90 days to return a payment to HHS, otherwise the recipient was deemed to have 
accepted the terms and conditions.  Our sample included PRF payments issued in CY 2020 for which hospitals 
attested to the payment terms and conditions and/or kept PRF payments after 90 days of receipt.   
 
35 A reporting TIN is one that is associated with a hospital entity that reports the use of PRF General and/or 
Targeted Distribution payments received by that TIN and/or its subsidiaries or is associated with a parent 
organization that is not a hospital entity (e.g., a holding corporation) but reports on the use of PRF payments for 
one or more of its subsidiaries that are hospital entities.  Each selected hospital TIN could be a stand-alone hospital 
or part of a parent-subsidiary system that may include other provider types (e.g., urgent care facilities, nursing 
homes, and clinics). 
 
36 We included a range of payments from $22.8 million to $435.3 million. 
 
37 The selection factors were designed to cover various types and sizes of hospitals nationwide. 
 
38 This report refers to bills for treatment as opposed to bills for COVID-19 inpatient services because some 
patients did not test positive for COVID-19.  However, because these patients presented on admission as 
potentially positive for COVID-19, all services for these patients fell under the balance billing requirement. 

 
Hospitals’ Compliance With Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
12 
(1) January 1, 2021, through March 31, 2021, and (2) January 1, 2022, through March 31, 2022 
(audit period).39 
 
We did not assess the overall internal control structure of HRSA or the hospitals.  We limited 
our review of HRSA’s and the selected hospitals’ internal controls to those applicable to our 
audit objective.  Specifically, we reviewed HRSA’s guidance to providers related to compliance 
with the balance billing requirement.  We also reviewed selected hospitals’ policies and 
procedures for compliance with the balance billing requirement.40 
 
We conducted our audit from July 2022 through June 2025.  
 
METHODOLOGY 
 
To accomplish our objective, we: 
 
• reviewed applicable Federal laws, regulations, and guidance, including the PRF terms 
and conditions and HRSA’s FAQs related to the balance billing requirement;  
 
• interviewed HRSA officials and obtained documentation to gain an understanding of the 
program’s policies and procedures and HRSA’s oversight and monitoring of the balance 
billing requirement;  
 
• conducted an analysis of insurance company waivers for COVID-19 treatment;41 
 
• obtained from HRSA a list of hospitals nationwide that received PRF payments; 
 
• created a list of 265 hospitals nationwide that kept PRF payments based on the: (1) type 
of hospital (e.g., long-term care facility, psychiatric hospital, CAHs), (2) hospital revenues 
for fiscal years 2017 and 2018, (3) amount of PRF payment kept,42 (4) geographical 
location (i.e., urban and rural), and (5) hospital bed count; 
 
• selected a nonstatistical sample of 25 hospitals nationwide (based on payment amount, 
geographic location, type of entity, and facility size) that received and kept 
 
39 We selected the two periods to compare and determine if any changes (e.g., expiration of an insurer’s waivers or 
updated HRSA guidance) impacted the sampled hospitals’ ability to comply with the balance billing requirement 
and did not identify any material differences in the hospitals’ compliance between the two periods. 
 
40 The conclusions derived from this audit were based on information provided by hospitals and publicly available 
information (e.g., websites) from insurance companies.  We did not contact insurance carriers or patients for 
support documentation or to conduct interviews. 
 
41 Our analysis of insurance company waivers for COVID-19 treatment determined that a vast majority of insurers 
waived out-of-pocket costs through January 2021. 
 
42 For this audit, we only considered hospitals that retained PRF payments of $10,000 or more. 

 
Hospitals’ Compliance With Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
13 
PRF payments made to each hospital’s TIN and had 4 or more patients with out-of-
network insurance coverage with either a positive COVID-19 test result or a COVID-19 
diagnosis code; 
 
• obtained hospital questionnaire responses from each selected hospital to identify the 
policies and procedures used to ensure compliance with the balance billing 
requirement; 
 
• obtained point-in-time patient census data from each selected hospital to identify out-
of-network presumptive and actual COVID-19 patients with Medicare Part C and private 
insurance during the audit period;43, 44 
 
• selected a nonstatistical sample of four out-of-network patients based on billed amount 
and insurance type (e.g., private, Medicare Part C, or Medicaid) from each hospital 
(100 patients in total) who were admitted for treatment with a positive COVID-19 test 
result or a COVID-19 diagnosis and obtained the hospital billing documentation for 
these selected patients;45, 46 
 
• determined, based on the billing documentation provided, whether the hospitals’ bills 
to selected patients treated for COVID-19 complied with the PRF’s balance billing 
requirement, and for each of the 100 patients: 
 
o obtained and analyzed the hospital’s billing documentation and related records;47 
 
43 The patient information obtained included the patient’s: personal information (e.g., name, medical identification 
number, address/contact information), insurance plan and coverage information (i.e., name of carrier, carriers’ 
contact information, and in-network/out-of-network status with the selected hospital), and COVID-19 diagnosis 
(actual, presumptive, or not applicable).  We used this data to identify out-of-network COVID-19 patients with 
Medicare Part C and private health insurance coverage. 
 
44 The 25 hospitals identified a total of 783 out-of-network patients admitted with a COVID-19 diagnosis during our 
audit period. 
 
45 Preliminary survey work determined that CAHs, primarily located in rural areas, were generally the only health 
care facility within a large geographic area.  As a result, CAHs generally did not have out-of-network patients.  
Therefore, we excluded CAHs from our sample. 
 
46 During our fieldwork, we found that for eight of our selected hospitals, the four patients we selected were not 
billed for the treatment provided because either there was no patient responsibility, or the hospital waived the 
patient’s responsibility.  Some hospitals opted to waive billing their patients due to uncertainty with how to 
comply with the requirement.  We note that HRSA established the ACA Marketplace out-of-pocket limitation as a 
compliance threshold as part of a technical update issued Apr. 6, 2022, which occurred after our audit period. 
 
47 The hospital billing documentation obtained included, but was not limited to: claim and billing documentation 
sent to the patient’s carrier(s), claim and billing resolution letter(s) from the carrier(s), billing documentation and 
notifications/correspondence sent to the patient, claim/billing reconciliation of the patient’s account, 
documentation used to determine/calculate the patient’s in-network cost, and any other relevant correspondence 
or documentation regarding the billing or collection of payments for the inpatient stay. 

 
Hospitals’ Compliance With Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
14 
 
o based on the hospital’s documentation, compared the carrier’s EOB to the hospital 
patient payment account and billing statement to determine whether the patient 
was billed and the amount of the bill; 
 
o confirmed with hospital staff whether the patient’s responsibility identified on the 
EOB was determined based on the in-network or out-of-network rate; and 
 
o determined whether the patient’s billed amount exceeded the allowable amount 
(i.e., the insurance carrier’s cost-share waiver [if any], the patient’s responsibility, or 
the ACA Marketplace out-of-pocket limitation). 
 
• discussed the results of our audit with HRSA officials.  
 
We conducted this performance audit in accordance with generally accepted government 
auditing standards.  Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions 
based on our audit objectives.  We believe that the evidence obtained provides a reasonable 
basis for our findings and conclusions based on our audit objectives. 
 
 

 
Hospitals’ Compliance With Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
15 
APPENDIX B: RELATED OFFICE OF INSPECTOR GENERAL REPORTS 
 
Report Title 
Report Number 
Date Issued 
Selected Home Health Agencies Complied With 
Terms and Conditions and Federal Requirements for 
Provider Relief Fund Payments 
A-01-22-00503 
11/26/2024 
Seven of Thirty Hospices Reviewed Did Not Comply or 
May Not Have Complied With Terms and Conditions 
and Federal Requirements for Provider Relief Fund 
Payments 
A-02-22-01014 
11/8/2024 
HRSA Made Some Potential Overpayments to 
Providers Under the Phase 2 General Distribution of 
the Provider Relief Fund Program 
A-09-22-06001 
3/4/2024 
The Provider Relief Fund Helped Select Nursing 
Homes Maintain Services During the COVID 19 
Pandemic, but Some Found Guidance Difficult To Use 
OEI-06-22-00040 
12/12/2023 
HHS’s Oversight of Automatic Provider Relief Fund 
Payments Was Generally Effective but Improvements 
Could Be Made 
A-02-20-01025 
10/30/2023 
HRSA Made COVID-19 Uninsured Program Payments 
to Providers on Behalf of Individuals Who Had Health 
Insurance Coverage and for Services Unrelated to 
COVID-19 
A-02-21-01013 
7/13/2023 
Targeted Provider Relief Funds Allocated to Hospitals 
Had Some Differences With Respect to the Ethnicity 
and Race of Populations Served 
OEI-05-20-00580 
7/12/2023 
HHS’s and HRSA’s Controls Related to Selected 
Provider Relief Fund Program Requirements Could Be 
Improved 
A-09-21-06001 
9/26/2022 

 
Hospitals’ Compliance With Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
16 
APPENDIX C: SUMMARY OF FINDINGS 
 
 
 
 
Errors 
Potential Errors 
 
 
 
Hospital 
Patient 
Patient 
Amount 
Billed 
Patient 
Billed 
When a 
Waiver 
Was in 
Place 
Patient 
Billed 
Out-of-
Network 
Amount 
Patient Bill 
Exceeded 
ACA 
Marketplace 
Out-of-
Pocket 
Limitation 
Hospital 
Did Not 
Confirm 
Amount 
Billed 
Hospital Did 
Not Confirm 
if There Was 
a Waiver 
Total 
Patient 
Improper 
and 
Potentially 
Improper 
Amount 
Total 
Hospital 
Errors 
and 
Potential 
Errors 
Total 
Hospital 
Improper 
and 
Potentially 
Improper 
Amount 
1 
A 
$0 
  
  
  
  
  
$0 
2 
$7,404 
B 
$6,404 
  
  
  
  
X 
$6,404 
C 
$0 
  
  
  
  
  
$0 
D 
$1,000 
  
  
  
  
X 
$1,000 
2 
A 
$1,950 
  
X 
  
  
  
$1,950 
4 
$6,585 
B 
$675 
  
X 
  
  
  
$675 
C 
$2,010 
  
X 
  
  
  
$2,010 
D 
$1,950 
  
X 
  
  
  
$1,950 
3 
A 
$0 
  
  
  
  
  
$0 
0 
$0 
B 
$0 
  
  
  
  
  
$0 
C 
$0 
  
  
  
  
  
$0 
D 
$0 
  
  
  
  
  
$0 
4 
A 
$0 
  
  
  
  
  
$0 
2 
$6,021 
B 
$6,000 
X 
  
  
  
  
$6,000 
C 
$21 
  
  
  
X 
  
$21 
D 
$0 
  
  
  
  
  
$0 
5 
A 
$0 
  
  
  
  
  
$0 
1 
$2,240 
B 
$0 
  
  
  
  
  
$0 
C 
$2,240 
  
  
  
X 
  
$2,240 
D 
$0 
  
  
  
  
  
$0 

 
Hospitals’ Compliance With Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
17 
 
 
 
Errors 
Potential Errors 
 
 
 
Hospital 
Patient 
Patient 
Amount 
Billed 
Patient 
Billed 
When a 
Waiver 
Was in 
Place 
Patient 
Billed 
Out-of-
Network 
Amount 
Patient Bill 
Exceeded 
ACA 
Marketplace 
Out-of-
Pocket 
Limitation 
Hospital 
Did Not 
Confirm 
Amount 
Billed 
Hospital Did 
Not Confirm 
if There Was 
a Waiver 
Total 
Patient 
Improper 
and 
Potentially 
Improper 
Amount 
Total 
Hospital 
Errors 
and 
Potential 
Errors 
Total 
Hospital 
Improper 
and 
Potentially 
Improper 
Amount 
6 
A 
$0 
  
  
  
  
  
$0 
1 
$100 
B 
$0 
  
  
  
  
  
$0 
C 
$0 
  
  
  
  
  
$0 
D 
$100 
  
  
  
X 
  
$100 
7 
A 
$0 
  
  
  
  
  
$0 
0 
$0 
B 
$0 
  
  
  
  
  
$0 
C 
$0 
  
  
  
  
  
$0 
D 
$0 
  
  
  
  
  
$0 
8 
A 
$2,010 
  
X 
  
  
  
$2,010 
4 
$6,559 
B 
$2,674 
X 
  
  
  
  
$2,674 
C 
$1,675 
  
X 
  
  
  
$1,675 
D 
$200 
  
X 
  
  
  
$200 
9 
A 
$0 
  
  
  
  
  
$0 
2 
$1,565 
B 
$1,158 
  
X 
  
  
  
$1,158 
C 
$0 
  
  
  
  
  
$0 
D48 
$407 
  
  
  
  
X 
$407 
10 
A 
$1,291 
X 
  
  
  
  
$1,291 
1 
$1,291 
B 
$0 
  
  
  
  
  
$0 
C 
$0 
  
  
  
  
  
$0 
D 
$0 
  
  
  
  
  
$0 
 
48 During our audit period, Patient D was billed by the sampled hospital for three separate inpatient visits for COVID-19 treatment.  The hospital billed the 
patient for only one of these visits. 

 
Hospitals’ Compliance With Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
18 
 
 
 
Errors 
Potential Errors 
 
 
 
Hospital 
Patient 
Patient 
Amount 
Billed 
Patient 
Billed 
When a 
Waiver 
Was in 
Place 
Patient 
Billed 
Out-of-
Network 
Amount 
Patient Bill 
Exceeded 
ACA 
Marketplace 
Out-of-
Pocket 
Limitation 
Hospital 
Did Not 
Confirm 
Amount 
Billed 
Hospital Did 
Not Confirm 
if There Was 
a Waiver 
Total 
Patient 
Improper 
and 
Potentially 
Improper 
Amount 
Total 
Hospital 
Errors 
and 
Potential 
Errors 
Total 
Hospital 
Improper 
and 
Potentially 
Improper 
Amount 
11 
A 
$2,592 
X 
  
  
  
  
$2,592 
3 
$7,230 
B 
$3,138 
  
  
  
  
X 
$3,138 
C 
$2,978 
  
  
  
  
  
$0 
D 
$1,500 
X 
  
  
  
  
$1,500 
12 
A 
$0 
  
  
  
  
  
$0 
0 
$0 
B 
$0 
  
  
  
  
  
$0 
C 
$0 
  
  
  
  
  
$0 
D 
$0 
  
  
  
  
  
$0 
13 
A 
$0 
  
  
  
  
  
$0 
0 
$0 
B 
$0 
  
  
  
  
  
$0 
C 
$0 
  
  
  
  
  
$0 
D 
$0 
  
  
  
  
  
$0 
14 
A 
$0 
  
  
  
  
  
$0 
0 
$0 
B 
$0 
  
  
  
  
  
$0 
C 
$0 
  
  
  
  
  
$0 
D 
$0 
  
  
  
  
  
$0 
15 
A 
$1,000 
  
  
  
X 
  
$1,000 
6 
$550,487 
B 
$118,131 
  
  
X 
 
  
$101,031 
C 
$296,224 
X 
  
X 
  
  
$296,224 
D 
$152,232 
X 
  
X 
  
  
$152,232 

 
Hospitals’ Compliance With Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
19 
 
 
 
Errors 
Potential Errors 
 
 
 
Hospital 
Patient 
Patient 
Amount 
Billed 
Patient 
Billed 
When a 
Waiver 
Was in 
Place 
Patient 
Billed 
Out-of-
Network 
Amount 
Patient Bill 
Exceeded 
ACA 
Marketplace 
Out-of-
Pocket 
Limitation 
Hospital 
Did Not 
Confirm 
Amount 
Billed 
Hospital Did 
Not Confirm 
if There Was 
a Waiver 
Total 
Patient 
Improper 
and 
Potentially 
Improper 
Amount 
Total 
Hospital 
Errors 
and 
Potential 
Errors 
Total 
Hospital 
Improper 
and 
Potentially 
Improper 
Amount 
16 
A 
$1,100 
  
  
  
X 
X 
$1,100 
4 
$1,956 
B 
$225 
  
  
  
X 
  
$225 
C 
$0 
  
  
  
  
  
$0 
D 
$631 
  
  
  
X 
  
$631 
17 
A 
$3,112 
  
  
  
X 
  
$3,112 
3 
$6,164 
B 
$1,452 
  
  
  
X 
  
$1,452 
C 
$7,235 
  
  
  
  
  
$0 
D 
$1,600 
  
  
  
X 
  
$1,600 
18 
A 
$300 
  
  
  
X 
  
$300 
4 
$1,800 
B 
$500 
  
  
  
X 
  
$500 
C 
$500 
  
  
  
X 
  
$500 
D 
$500 
  
  
  
X 
  
$500 
19 
A 
$0 
  
  
  
  
  
$0 
1 
$5,236 
B 
$0 
  
  
  
  
  
$0 
C 
$0 
  
  
  
  
  
$0 
D 
$5,236 
  
  
  
X 
  
$5,236 
20 
A 
$0 
  
  
  
  
  
$0 
0 
$0 
B 
$0 
  
  
  
  
  
$0 
C 
$0 
  
  
  
  
  
$0 
D 
$0 
  
  
  
  
  
$0 

 
Hospitals’ Compliance With Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
20 
 
 
 
Errors 
Potential Errors 
 
 
 
Hospital 
Patient 
Patient 
Amount 
Billed 
Patient 
Billed 
When a 
Waiver 
Was in 
Place 
Patient 
Billed 
Out-of-
Network 
Amount 
Patient Bill 
Exceeded 
ACA 
Marketplace 
Out-of-
Pocket 
Limitation 
Hospital 
Did Not 
Confirm 
Amount 
Billed 
Hospital Did 
Not Confirm 
if There Was 
a Waiver 
Total 
Patient 
Improper 
and 
Potentially 
Improper 
Amount 
Total 
Hospital 
Errors 
and 
Potential 
Errors 
Total 
Hospital 
Improper 
and 
Potentially 
Improper 
Amount 
21 
A 
$0 
  
  
  
  
  
$0 
2 
$25,037 
B 
$0 
  
  
  
  
  
$0 
C 
$0 
  
  
  
  
  
$0 
D 
$25,037 
X 
  
X 
  
  
$25,037 
22 
A 
$0 
  
  
  
  
  
$0 
0 
$0 
B 
$0 
  
  
  
  
  
$0 
C 
$0 
  
  
  
  
  
$0 
D 
$0 
  
  
  
  
  
$0 
23 
A 
$0 
  
  
  
  
  
$0 
0 
$0 
B 
$0 
  
  
  
  
  
$0 
C 
$0 
  
  
  
  
  
$0 
D 
$0 
  
  
  
  
  
$0 
24 
A 
$1,375 
X 
  
  
  
  
$1,375 
4 
$5,980 
B 
$1,975 
  
  
  
X 
  
$1,975 
C 
$910 
  
  
  
X 
  
$910 
D 
$1,720 
  
  
  
  
X 
$1,720 
25 
A 
$226 
  
  
  
  
  
$0 
1 
$1,380 
B 
$86 
  
  
  
  
  
$0 
C 
$440 
  
  
  
  
  
$0 
D 
$1,380 
  
  
  
  
X 
$1,380 
Total 
 
$665,100 
9 
8 
4 
17 
7 
 
45 
$637,035 
 

 
Hospitals’ Compliance With Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
21 
APPENDIX D: HRSA COMMENTS 
 

 
Hospitals’ Compliance With Provider Relief Fund Balance Billing Requirement (A-02-22-01018) 
22 
 
Draft Report titled “Seventeen of Twenty-Five Selected Hospitals 
Did Not Comply or May Not Have Complied With the Provider 
Relief Fund Balance Billing Requirement, A-02-22-01018” 
General Comments 
The Health Resources and Services Administration (HRSA) appreciates the opportunity to 
comment on the Office of Inspector General’s (OIG) draft audit report titled “Seventeen of 
Twenty-Five Selected Hospitals Did Not Comply or May Not Have Complied With the Provider 
Relief Fund Balance Billing Requirement.” 
HRSA’s responses to the OIG Draft Report recommendations are as follows: 
OIG Recommendation 1 
The OIG recommended that HRSA determine whether the selected hospitals made refunds to the 
patients identified in this audit for billings that did not or may not have complied with the PRF 
balance billing requirement. 
HRSA Response 
HRSA concurs with the OIG recommendation. HRSA will review the selected hospitals’ 
compliance with the Provider Relief Fund (PRF) balance billing prohibition and request that the 
hospitals make refunds to patients, as appropriate. 
OIG Recommendation 2 
The OIG recommended that as part of its established and ongoing program integrity procedures, 
HRSA perform postpayment reviews of hospitals for compliance with the balance billing 
requirement, including the hospitals OIG identified that may not have complied, to ensure that 
patients were not billed more than their in-network amount and were refunded any improper 
billed amounts. 
HRSA Response 
HRSA concurs with the OIG recommendation. HRSA will determine if hospital providers 
selected for a PRF programmatic audit met the Terms and Conditions, including the prohibition 
of balance billing. 
 

1 
Report Fraud, Waste, 
and Abuse 
OIG Hotline Operations accepts tips and complaints from all sources about 
potential fraud, waste, abuse, and mismanagement in HHS programs.  Hotline 
tips are incredibly valuable, and we appreciate your efforts to help us stamp 
out fraud, waste, and abuse. 
TIPS.HHS.GOV 
Phone: 1-800-447-8477 
TTY: 1-800-377-4950  
Who Can Report? 
Anyone who suspects fraud, waste, and abuse should report their concerns 
to the OIG Hotline.  OIG addresses complaints about misconduct and 
mismanagement in HHS programs, fraudulent claims submitted to Federal 
health care programs such as Medicare, abuse or neglect in nursing homes, 
and many more.  Learn more about complaints OIG investigates. 
How Does It Help? 
Every complaint helps OIG carry out its mission of overseeing HHS programs 
and protecting the individuals they serve.  By reporting your concerns to the 
OIG Hotline, you help us safeguard taxpayer dollars and ensure the success of 
our oversight efforts. 
Who Is Protected? 
Anyone may request confidentiality.  The Privacy Act, the Inspector General 
Act of 1978, and other applicable laws protect complainants.  The Inspector 
General Act states that the Inspector General shall not disclose the identity of 
an HHS employee who reports an allegation or provides information without 
the employee’s consent, unless the Inspector General determines that 
disclosure is unavoidable during the investigation.  By law, Federal employees 
may not take or threaten to take a personnel action because of 
whistleblowing or the exercise of a lawful appeal, complaint, or grievance 
right.  Non-HHS employees who report allegations may also specifically 
request confidentiality. 

1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stay In Touch 
Follow HHS-OIG for up to date news and publications. 
OIGatHHS 
HHS Office of Inspector General 
Subscribe To Our Newsletter 
OIG.HHS.GOV 
Contact Us 
For specific contact information, please visit us online. 
U.S. Department of Health and Human Services 
Office of Inspector General 
Public Affairs 
330 Independence Ave., SW 
Washington, DC 20201 
Email: Public.Affairs@oig.hhs.gov

File and source

File

HHS-OIG_A-02-22-01018_Seventeen-of-Twentyfive-Hospitals-PRF-Balance-Billing_2025.pdf

Size

1,656,306 bytes

SHA-256

966c71c0a3851bca11f07073d1ad7f3d92c4d53a0b9f3a8b194dd3405cae3cce

Our copy

HHS-OIG_A-02-22-01018_Seventeen-of-Twentyfive-Hospitals-PRF-Balance-Billing_2025.pdf

Original

oig.hhs.gov