Four of Thirty Selected Dental Providers Did Not Comply With Terms and Conditions and Federal Requirements for Expending Provider Relief Fund Payments, A-02-23-01013
What This Document Is
This OIG audit report from U.S. Department of Health and Human Services Office of Inspector General examines Provider Relief Fund through the source document titled "Four of Thirty Selected Dental Providers Did Not Comply With Terms and Conditions and Federal Requirements for Expending Provider Relief Fund Payments". Congress appropriated $178 billion to HHS to provide funds to eligible providers for health care-related expenses or lost revenues 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.
Factual Summary
The source reports these central findings: Of the 30 selected dental providers we reviewed, 4 dental providers inaccurately calculated and reported $3.4 million of lost revenues. These four dental providers received a total of $14.8 million in PRF payments. The remaining dental providers used PRF payments for allowable expenses and accurately calculated lost revenues.
Recommendation or agency-response note: We recommend that HRSA require the selected dental providers to return to the Federal Government any PRF payments used to offset inaccurately calculated lost revenue amounts or properly account for these lost revenues. HRSA concurred with our recommendation.
Key Facts
- Document title: Four of Thirty Selected Dental Providers Did Not Comply With Terms and Conditions and Federal Requirements for Expending Provider Relief Fund Payments.
- Report number: A-02-23-01013.
- Document date shown in source front matter: November 2025.
- Issuer/court: U.S. Department of Health and Human Services Office of Inspector General.
- Document type: OIG audit report.
- Program(s): Provider Relief Fund.
- Review purpose: Congress appropriated $178 billion to HHS to provide funds to eligible providers for health care-related expenses or lost revenues 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.
- Primary source finding: Of the 30 selected dental providers we reviewed, 4 dental providers inaccurately calculated and reported $3.4 million of lost revenues. These four dental providers received a total of $14.8 million in PRF payments. The remaining dental providers used PRF payments for allowable expenses and accurately calculated lost revenues.
- Recommendation/status note: We recommend that HRSA require the selected dental providers to return to the Federal Government any PRF payments used to offset inaccurately calculated lost revenue amounts or properly account for these lost revenues. HRSA concurred with our recommendation.
Source Caveats
- Use the PDF for exact quotations, pagination, tables, figures, appendices, and agency-response language.
- Where the source uses samples, surveys, snapshots, or selected files, do not generalize beyond the scope stated in the report.
- Document type
- Audit
- Date
- 2020-03-13
Cite this document
“Four of Thirty Selected Dental Providers Did Not Comply With Terms and Conditions and Federal Requirements for Expending Provider Relief Fund Payments, A-02-23-01013.”
Original at oig.hhs.gov, dated 2020-03-13. Archived at Pandemic Darlings, https://pandemicdarlings.com/source-documents/2020-03-13-four-of-thirty-selected-dental-providers-did-not-comply-with-terms-and-conditio/
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November 2025 | A-02-23-01013
Four of Thirty Selected Dental
Providers Did Not Comply With
Terms and Conditions and Federal
Requirements for Expending
Provider Relief Fund Payments
OIG.HHS.GOV
November 2025 | A-02-23-01013
Four of Thirty Selected Dental Providers Did Not Comply With Terms
and Conditions and Federal Requirements for Expending Provider Relief
Fund Payments
Why OIG Did This Audit
• Congress appropriated $178 billion to HHS to provide funds to eligible providers for health care-related
expenses or lost revenues 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.
• Providers receiving PRF payments were to ensure that the payments were: (1) used to prevent,
prepare for, or respond to COVID-19; (2) used for health care-related expenses or lost revenues
attributable to COVID-19; (3) not used to cover expenses or losses reimbursed by other funding
sources; and (4) not used to pay salaries in excess of a certain threshold or to pay for certain prohibited
activities.
• This audit is part of a series reviewing PRF payments to various provider types. Specifically, this audit
assessed whether 30 selected dental providers expended taxpayer funds in accordance with Federal
and program requirements.
What OIG Found
• Of the 30 selected dental providers we reviewed, 4 dental providers inaccurately calculated and
reported $3.4 million of lost revenues. These four dental providers received a total of $14.8 million in
PRF payments. The remaining dental providers used PRF payments for allowable expenses and
accurately calculated lost revenues.
• These deficiencies occurred because although dental providers attested to the PRF terms and
conditions and HRSA provided continuously updated guidance to PRF recipients, some dental providers
misinterpreted HRSA’s guidance on calculating patient care lost revenues and used incorrect revenue
amounts in their lost revenue calculations.
What OIG Recommends
We recommend that HRSA require the selected dental providers to return to the Federal Government any PRF
payments used to offset inaccurately calculated lost revenue amounts or properly account for these lost
revenues. HRSA concurred with our recommendation.
OIG.HHS.GOV
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 ........................ 3
Requirements for Dental Providers That Received Provider Relief Fund
Payments .............................................................................................................. 4
How We Conducted This Audit ........................................................................................... 6
FINDINGS ......................................................................................................................................... 7
Some Dental Providers Inaccurately Calculated and Reported Lost Revenues ................. 7
Causes of Inaccurately Calculated and Reported Lost Revenues ....................................... 8
RECOMMENDATION ....................................................................................................................... 9
OTHER MATTERS ............................................................................................................................. 9
HEALTH RESOURCES AND SERVICES ADMINISTRATION COMMENTS AND OFFICE OF
INSPECTOR GENERAL RESPONSE ............................................................................................... 10
APPENDICES
A: Audit Scope and Methodology ..................................................................................... 11
B: Related Office of Inspector General Reports................................................................ 14
C: Provider Relief Fund General and Targeted Distribution Payments ............................ 15
D: Options for Calculating Lost Revenues......................................................................... 17
E: Selected Dental Providers’ Reported Use of Provider Relief
Fund Payments for Reporting Periods 2 and 3 ........................................................... 18
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013)
F: Summary of Sampled Dental Providers’ Inaccurately Calculated and Reported
Lost Revenue Amounts ............................................................................................... 19
G: Other Matters – Potential Savings Calculations........................................................... 21
H: Health Resources and Services Administration Comments ......................................... 23
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013)
INTRODUCTION
WHY WE DID THIS AUDIT
On March 13, 2020, the President declared the COVID-19 outbreak a national emergency. In
response, Congress passed three bills, which the President signed into law. These Federal laws
appropriated to the Department of Health and Human Services (HHS) a combined $178 billion
in funds, part of which HHS used to establish the Provider Relief Fund (PRF). 1 The PRF provided
payments 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. HHS distributed PRF funds, in
part, as direct payments to providers in a series of PRF General and Targeted Distributions.2 As
of October 2024, the Health Resources and Services Administration (HRSA) had distributed
$145.9 billion of the PRF to providers. 3
This audit assessed selected dental providers’ compliance with terms and conditions and
Federal requirements for expending PRF payments. It is one of several Office of Inspector
General (OIG) audits of various aspects of PRF payments, including: (1) HHS’s and 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, and (3) claims for COVID-19 testing and
treatment services for uninsured individuals. See Appendix B for a list of related OIG reports.
1
Specifically, 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). 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 eligible providers or specific provider types to address added COVID-19
challenges, such as high-need populations, including nursing facilities and providers serving individuals in rural
areas and safety net hospitals.
3
This dollar figure is based on latest PRF distribution data provided by HRSA. As of June 2023, with the passage of
the Fiscal Responsibility Act of 2023, P.L. No. 118-5, Congress rescinded unobligated PRF funds, except for limited
funding Congress directed be used for program oversight and administration. In response, HRSA stopped making
PRF payments to providers.
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 1
OBJECTIVE
Our objective was to determine whether selected dental providers that received PRF payments
complied with terms and conditions and Federal requirements for expending PRF funds.
BACKGROUND
The Provider Relief Fund
As a result of the COVID-19 public health emergency, many States ordered health care facilities,
physicians, and other providers and professionals to delay elective or nonurgent procedures to
conserve personal protective equipment and free up staff and facilities for COVID-19 patients.4
Many dental providers reported that their cash reserves were quickly depleted, which could
have disrupted ongoing dental provider operations. Many of these providers, especially small
rural dental providers, requested financial assistance, including loans and grants.
In response to the public health emergency, the PRF was established to provide funds to
eligible providers for health care-related expenses or lost revenues attributable to COVID-19. 5
HHS received a combined $178 billion in funding, of which $145.9 billion was distributed via PRF
payments to providers. 6 PRF funds were distributed as direct payments to providers in a series
of General and Targeted Distributions.
The Exhibit on the next page details the PRF distributions to health care providers. For further
details on how PRF payments were distributed, see Appendix C.
4
On Jan. 31, 2020, the Secretary of Health and Human Services declared the COVID-19 outbreak a public health
emergency. Then, on Mar. 13, 2020, the President declared the COVID-19 outbreak a national emergency. Both
the COVID-19 public health and national emergencies ended on May 11, 2023.
5
Providers had up to the end of the quarter in which the public health emergency ended (June 30, 2023) to use
PRF payments for any lost revenues attributable to COVID-19.
6
Congress also appropriated $8.5 billion of COVID-19-related relief for rural providers enrolled in Medicare or
Medicaid programs (American Rescue Plan Act of 2021, P.L. No. 117-2). This funding was administered by HRSA
and had similar limitations and requirements as the PRF but was not part of the PRF.
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 2
Exhibit: Provider Relief Fund Distributions to Health Care Providers
Notes: Amounts for the Targeted Distributions do not add to $57.5 billion due to rounding. CHIP stands for the
Children’s Health Insurance Program.
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 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
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 3
COVID-19. Within HHS, HRSA was responsible for providing day-to-day oversight and managed
all aspects of the PRF program. 7
HRSA provided various resources to providers on the proper use and reporting of PRF
payments, including issuing a collection of evolving Frequently Asked Questions (FAQs), and
other guidance on allowable expenses and lost revenue calculations.8 HRSA also conducted
technical assistance webinars on the reporting process. In addition, HRSA engaged external
audit firms to conduct risk-based audits for a sample of providers to ensure that providers used
PRF payments in accordance with PRF terms and conditions.
Requirements for Dental Providers That Received Provider Relief Fund Payments
Providers, including dental providers, may have been eligible to receive PRF payments from
multiple distributions. 9, 10 Dental providers that received PRF payments had to comply with
certain provisions of the Uniform Administrative Requirements, Cost Principles, and Audit
Requirements for HHS Awards (45 CFR part 75). Specifically, the dental providers had to
comply with 45 CFR § 75.302 (Financial management and standards for financial management
systems) and 45 CFR §§ 75.361 through 75.365 (Record retention and access).
As a condition of receiving PRF payments, providers agreed to the PRF terms and conditions,
including meeting eligibility criteria; filing expenditure reports; and ensuring that payments
were: (1) used to prevent, prepare for, or respond to COVID-19; (2) used for health care-related
7
HHS and HRSA, PRF General & Targeted Distribution Cycle Memo, dated Sept. 30, 2020, and Sept. 30, 2021.
8
HRSA, Provider Relief Programs: Provider Relief Fund and ARP Rural Payments Frequently Asked Questions (PRF
FAQs). Accessed on June 27, 2025. HRSA, Provider Relief Fund Distributions and American Rescue Plan Rural
Distribution Post-Payment Notice of Reporting Requirements (PRF Reporting Requirements). Accessed on June 27,
2025.
9
PRF payments were distributed to providers based on providers’ taxpayer identification numbers (TINs). Dental
providers and other providers were required to report on their PRF payments if they received $10,000 or more
during a specified timeframe (i.e., payment period). For providers to meet this requirement, HRSA established
reporting periods, which specified when providers had to report on the use of PRF payments and were based on
the payment period(s). For example, reporting periods 2 and 3 covered PRF payments received during the period
from July 1, 2020, through June 30, 2021. We use the term “dental provider” to refer to a dental reporting entity.
A dental reporting entity may have registered its TIN through the PRF Reporting Portal to report to HRSA on the use
of PRF payments received by that TIN and TINs associated with the entity’s subsidiary entities (e.g., individual
dental providers). A dental provider may be a stand-alone dental provider, a dental provider group, or a parent
organization.
10
For details on General and Targeted Distribution payments, see Appendix C. In addition to PRF payments, dental
providers may have received COVID-19-related assistance from other sources such as the Federal Emergency
Management Agency, the Department of the Treasury, and the Small Business Administration, as well as grants and
donations from local and State governments or private sources.
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 4
expenses or lost revenues (i.e., patient care revenues) attributable to COVID-19; 11 (3) not used
to reimburse expenses or losses already reimbursed from other funding sources; and (4) not
used to pay salaries in excess of a certain threshold or to pay for certain prohibited activities
(e.g., lobbying). 12
Provider Relief Fund Expenditures and Lost Revenues
For reporting purposes, HRSA established periods during which providers were required to use
and report on PRF payments.13 Providers, including dental providers, were required to report
on their use of PRF payments in broad categories (i.e., lost revenues, health care-related
expenses, or general and administrative expenses). For expenses, dental providers were
required to report their use of PRF payments for health care-related expenses (e.g., expenses
for purchasing equipment such as face shields and sanitizing supplies for infection control) and
general and administrative expenses (e.g., salaries, utilities, rent), including expenses incurred
prior to receipt of PRF payments (i.e., pre-award costs dated back to January 1, 2020). 14 Dental
providers were required to follow their basis of accounting (cash or accrual basis) to determine
expenses and only use PRF payments for eligible expenses or lost revenues during what is
known as the period of availability. 15
For lost revenues, dental providers could apply their PRF payments toward lost revenue
amounts during a period of availability calculated using one of the following three options:
1. the difference between actual patient care revenues from 2019 and actual patient care
revenues during the period of availability,
2. the difference between budgeted patient care revenues (approved by dental provider
management prior to March 27, 2020) and actual patient care revenues, or
11
Patient care means health care, services, and supports, as provided in a medical setting, at home, via telehealth,
or in the community. Items not considered patient care revenue include nonpatient care dining services, grants,
bad debt, any gains or losses on investments, and contractual adjustments.
Recipients were not allowed to use PRF payments to pay any salary at a rate in excess of Executive Level II, which
12
was set at $197,300 for 2020 and $199,300 for 2021.
13
HRSA required all providers that received PRF payments exceeding $10,000 in the aggregate during any given
payment-received periods (i.e., time periods in which a health care provider received one or more PRF payments)
to report on their use of the payments during the applicable reporting period.
14
HRSA, PRF Reporting Requirements.
15
The period of availability ends 1 year after the end of the quarter or semiannual period in which the payment
was received. The first payment receipt period was Apr. 10, 2020, through June 30, 2020. Subsequent payment
receipt periods were 6 months.
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 5
3. any reasonable method of estimating revenues. 16
HRSA guidance for the treatment of unallowable or ineligible expenditures of PRF funds stated
that providers were allowed to replace unallowable or ineligible expenditures allocated to PRF
payments in a closed reporting period with unreimbursed lost revenues in subsequent
reporting periods. Providers were not required to return PRF payments used for unallowable
purposes (e.g., lobbying) to the Federal Government if they had sufficient unreimbursed lost
revenues to offset unallowable amounts. See Appendix D for a detailed description of how
providers could choose to calculate lost revenues.
HOW WE CONDUCTED THIS AUDIT
Our audit covered $123 million in PRF payments to a nonstatistical sample of 30 dental provider
taxpayer identification numbers (TINs) during the period from July 1, 2020, through June 30,
2021 (audit period). (We refer to these sample units throughout the report as “dental
providers.”) 17 The selected dental providers reported that they used $48.7 million of their PRF
payments for general and administrative expenses, $8.3 million for health care-related
expenses, and $66 million to offset lost revenues. 18 Appendix E contains details on how the
selected dental providers used PRF payments issued during the audit period.
We selected the dental providers based on an analysis that considered the amount of PRF
payments received and geographic location (i.e., areas most impacted by COVID-19, urban and
rural areas). 19 We reviewed the dental providers’ PRF payments used to cover general and
administrative and health care-related expenses or to offset lost patient care revenues.
Specifically, for each of the selected dental providers that reported expenditures, we reviewed
a nonstatistical sample of expenses that we selected based on materiality and expense
descriptions (e.g., salaries, supplies, and equipment). For the selected dental providers that
16
For payments received in periods 5, 6, or 7, the period of availability to use PRF payments for lost revenues
attributable to COVID-19 ended June 30, 2023, the end of the quarter in which the COVID-19 public health
emergency ended (HRSA, PRF Reporting Requirements).
17
The sampling frame consisted of 51,403 dental providers that received and kept 1 or more PRF payments totaling
approximately $3.1 billion. 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 dental providers that
received PRF payments issued during the audit period and for which dental providers attested to the payment
terms and conditions or were deemed to have accepted the terms and conditions.
18
Dental providers reported these amounts on expenditure reports submitted to HRSA for reporting periods 2
and 3.
19
Our sample unit was a dental provider that reported the use of PRF General Distribution payments. Each
sampled dental provider could be a stand-alone dental provider or part of a parent-subsidiary system that may
include a parent company and one or more subsidiary dental providers. The 30 selected dental providers received
from $441,000 to $15.7 million in PRF payments during the audit period and were located in 18 States. Twenty-two
of the dental providers were stand-alone dental providers and eight were part of parent-subsidiary systems.
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 6
reported lost revenues, we reviewed the dental providers’ lost revenue calculations and
supporting accounting records. 20
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 30 selected dental providers, 26 used the funds for allowable general and administrative
and health care-related expenses and to offset accurately calculated lost revenues attributable
to COVID-19. However, the remaining four dental providers did not comply with Federal
requirements. Specifically, the four dental providers inaccurately calculated and reported lost
revenues. These deficiencies occurred because although dental providers attested to the PRF
terms and conditions and HRSA provided continuously updated guidance to PRF recipients,
some dental providers misinterpreted HRSA’s guidance on calculating patient care lost
revenues and used incorrect revenue amounts in their lost revenue calculations.
As a result of these deficiencies, 4 of the 30 selected dental providers inaccurately reported lost
revenues totaling $3.4 million. 21 These funds could have been used to offset allowable lost
revenues or to support other activities related to the COVID-19 public health emergency,
including preventing, preparing for, and responding to COVID-19.
Appendix F contains a summary of our audit results for the sampled dental providers.
SOME DENTAL PROVIDERS INACCURATELY CALCULATED AND REPORTED LOST REVENUES
PRF payment amounts not fully expended on health care-related expenses attributable to
COVID-19 may be applied to lost revenues. Lost revenues can be calculated by one of three
options, including determining the difference between actual 2019 patient care revenues and
actual patient care revenues during the period of availability.22, 23 In addition, HRSA’s guidance
for lost revenue calculations provided recipients flexibility in the reconciliation of lost revenues
20
Of the 30 dental providers, 14 dental providers reported both expenses and lost revenues, 8 dental providers
reported only expenses, and 8 dental providers reported only lost revenues.
21
Specifically, the four dental providers inaccurately reported lost revenues totaling $3,381,110.
22
HRSA, PRF Reporting Requirements.
23
HRSA, “How to Calculate Lost Revenues for PRF and ARP Rural Reporting.” Accessed on June 27, 2025.
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 7
among parent entities and subsidiaries. However, HRSA’s FAQs stated that expenses and lost
revenues may not be duplicated, and payments may not be applied to the same expenses and
lost revenues that were reported on in prior reporting periods. 24
Four dental providers inaccurately calculated and reported lost revenues totaling $3.4 million.
Specifically:
• One dental provider overstated its lost revenues by $842,000 because it incorrectly used
estimated revenue summary amounts instead of actual general ledger amounts to
calculate its 2020 lost revenues.
• One dental provider overstated its lost revenues by $1.59 million because it incorrectly
used 2019 actual patient care revenue amounts that included other nonservice
revenues as the baseline to calculate its 2020 and 2021 lost revenues.
• One dental provider overstated its lost revenues by $903,000 because it incorrectly
added bad debts and other revenue adjustments to gross revenues to calculate its 2020
and 2021 patient care lost revenues.25
• One dental provider overstated its lost revenues by $48,000 because it did not account
for some prior period adjustments for dues, fees, other incomes, and refunds to
calculate its 2020 and 2021 lost revenues.
CAUSES OF INACCURATELY CALCULATED AND REPORTED LOST REVENUES
These deficiencies occurred because although dental providers attested to the PRF terms and
conditions and HRSA provided continuously updated guidance to PRF recipients, the dental
providers misinterpreted HRSA’s guidance on calculating patient care lost revenues and used
incorrect revenue amounts in their lost revenue calculations.
Further, in the context of extraordinary challenges from the COVID-19 public health emergency,
HRSA’s operational objective at the beginning of the public health emergency was to rapidly
disburse PRF payments to support providers facing severe economic hardship. In addition,
some dental providers indicated that they had a lack of staffing resources and unusually high
staff turnover. These and other unprecedented challenges of the pandemic may have
contributed to calculation errors when dental providers reported lost revenues or caused staff
to misinterpret HRSA’s guidance.
24
HRSA, PRF FAQs.
25
The dental provider should have deducted these amounts because HRSA’s definition of patient care revenue does
not include bad debts and other revenue adjustments.
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 8
In addition to the recommendation below, key stakeholders and decisionmakers should use the
information included in this report when determining lessons learned from administering PRF
distributions during the COVID-19 public health emergency and look for additional ways to
safeguard Federal funds when rapidly disbursing assistance payments to providers in response
to future public health emergencies.
RECOMMENDATION
We recommend that the Health Resources and Services Administration require the four dental
providers that we determined as having inaccurately calculated and reported lost revenues
totaling $3.4 million to identify and return to the Federal Government any PRF payments used
to offset inaccurately calculated lost revenues or replace them with allowable unreimbursed
lost revenues or eligible expenses, if any.
OTHER MATTERS
PRF payment amounts not fully expended on health care-related expenses attributable to
COVID-19 may be applied to patient care lost revenues. As noted previously, recipients could
choose to apply PRF payments toward lost revenues using one of the following three options:
1. the difference between actual patient care revenues from 2019 and actual patient care
revenues during the period of availability,
2. the difference between budgeted patient care revenues (approved by dental provider
management prior to March 27, 2020) and actual patient care revenues, or
3. any reasonable method of estimating revenues.
HRSA’s guidance allowed recipients to calculate lost revenues as a stand-alone quarterly
calculation and consider only those quarters with lost revenues to determine total loss amounts
for each reporting period. 26 Option 3 provided reporting entities additional flexibility in the
reconciliation of lost revenues among parent and subsidiary entities, including the application
of lost revenues attributable to COVID-19.
Twenty-two of the thirty selected dental providers reported lost revenues totaling $349.4
million. For these dental providers, we recalculated the reported lost revenues to determine
what these amounts would have been on an annual basis under option 1 (i.e., comparing 2019
actual patient care revenues to 2020 and 2021 actual patient care revenues). 27 If HRSA had
required reporting entities to use option 1 and annualize their revenues instead of allowing
26
HRSA’s PRF FAQs.
27
The PRF expenditure reports for the payment period ending Dec. 31, 2020, were due on Mar. 31, 2022. The
expenditure reports for the payment period ending June 30, 2021, were due on Sept. 30, 2022. Therefore, actual
patient care revenues for the audit period would have been available prior to the PRF report due dates.
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 9
stand-alone quarterly calculations, 16 of the 22 dental providers would not have been able to
report a total of $59 million in lost revenues and would not be able to apply PRF payments to
offset this amount.28 For any PRF payments applied against these excess lost revenue amounts,
the PRF payments could have been used for other purposes that supported dental providers’
activities (e.g., upgrading HVAC systems, purchasing cleaning supplies and personal protective
equipment) related to the COVID-19 public health emergency. For further details, see
Appendix G.
HEALTH RESOURCES AND SERVICES ADMINISTRATION COMMENTS AND
OFFICE OF INSPECTOR GENERAL RESPONSE
In written comments on our draft report, HRSA concurred with our recommendation and
indicated that it will review the relevant records and seek repayment, as appropriate.
Regarding our Other Matters section, HRSA noted that it was legally required to allow providers
to use “any reasonable” method to determine revenue losses, and OIG’s analysis and
conclusion were at odds with flexibilities afforded to providers.
We acknowledge that certain flexibilities were available to providers for lost revenue
calculations. However, we maintain that calculating revenue losses by comparing year-over-
year actual patient service revenues would have resulted in a more efficient use of PRF
payments.
HRSA also provided technical comments, which we addressed as appropriate. HRSA’s
comments, excluding the technical comments, are included as Appendix H.
28
Of the 22 dental providers that reported lost revenues, 17 dental providers used option 1 to report their lost
revenues and 5 dental providers used option 3. The $59 million of potential savings from recalculated lost
revenues includes the $3.4 million of lost revenues inaccurately calculated and reported by the four dental
providers identified earlier in the report.
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 10
APPENDIX A: AUDIT SCOPE AND METHODOLOGY
SCOPE
We identified 51,403 dental providers that received and kept 1 or more PRF payments totaling
approximately $3.1 billion during the period from July 1, 2020, through June 30, 2021 (audit
period). We selected for audit a nonstatistical sample of 30 dental providers that received PRF
payments from General Distributions totaling $123 million during the audit period. 29 We
selected the dental providers based on a risk analysis that included geographic locations (i.e.,
COVID-19 high-impact areas, urban and rural areas) and total PRF payment amounts. We
reviewed the selected dental providers’ PRF payments used to cover general and administrative
and health care-related expenses or to offset lost patient care revenues.
We limited our review of HRSA’s and the selected dental providers’ internal controls to those
applicable to our audit objective. We did not assess HRSA’s or the dental providers’ overall
internal control structure. Specifically, we reviewed HRSA’s policies and procedures for
reviewing expenditure information submitted by providers and its guidance to providers on the
use and reporting of PRF payments. We also reviewed selected dental providers’ policies and
procedures for monitoring, tracking, and expending PRF payments.
We established reasonable assurance of the authenticity and accuracy of the PRF payment data
by reconciling it with PRF expenditure reports submitted by dental providers through HRSA’s
PRF Reporting Portal.
We conducted our audit from June 2023 through July 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 providers’ use of PRF payments;
• met with HRSA officials to gain an understanding of the PRF’s payment terms and
conditions, reporting requirements, and HRSA’s monitoring and oversight activities;
• reviewed HRSA’s policies and procedures related to its oversight of recipients’ reporting
on the use of PRF funds and compliance with the terms and conditions for PRF
payments;
29
The sampling frame consisted of 51,403 dental providers that received and kept 1 or more PRF payments totaling
approximately $3.1 billion. 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 dental providers that
received PRF payments during the audit period for which the dental providers attested to the payment terms and
conditions or were deemed to have accepted the terms and conditions.
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 11
• obtained PRF payment data for General Distributions during the audit period;
• compiled a list of 51,403 dental providers nationwide that received and kept PRF
payments from General Distributions; 30
• selected a nonstatistical sample of 30 dental providers that received PRF payments
based on the amounts of PRF payments received and geographical locations (areas most
impacted by COVID-19 as well as urban and rural areas); 31
• for each dental provider selected for audit, interviewed dental provider representatives;
reviewed its expenditure reports submitted to HRSA and a nonstatistical sample of
expenses based on materiality and expense descriptions; and analyzed supporting
accounting, personnel, and other records to determine whether:
o payments were used only to prevent, prepare for, and respond to COVID-19;
o payments were used for health care-related or general and administrative
expenses or were applied to offset eligible lost revenues attributable to COVID-
19, and whether the amount for any lost revenues applied toward PRF payments
was accurately calculated; 32
o payments were not used to pay for expenses or losses reimbursed or eligible for
reimbursement from other funding sources (e.g., reimbursements from the
Federal Emergency Management Agency, Medicare/Medicaid or commercial
health insurance, the Paycheck Protection Program, and assistance from State or
local government agencies); and
o payments were not used to pay salaries at a rate in excess of certain thresholds
or for other prohibited activities.
• 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
30
We obtained from HRSA lists of TINs associated with dental providers that received PRF payments from Phase 2
and Phase 3 General Distributions and then extracted PRF payments for these TINs from the PRF payments
attestation file provided by OIG’s Division of Data Analytics.
31
The 30 selected dental providers received between $441,000 and $15.7 million in PRF payments during the audit
period and were located in 18 States.
32
We recalculated lost revenue amounts using the same option that the entity used for determining lost revenues.
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 12
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.
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 13
APPENDIX B: RELATED OFFICE OF INSPECTOR GENERAL REPORTS
Report Title Report Number Date Issued
Seventeen of Twenty-Five Selected Hospitals Did Not
Comply or May Not Have Complied With the Provider A-02-22-01018 9/19/2025
Relief Fund Balance Billing Requirement
Eleven of Thirty Selected Hospitals Did Not Comply
With Terms and Conditions and Federal Requirements A-02-22-01003 6/11/2025
for Expending Provider Relief Fund Payments
Ten of Thirty Selected Nursing Facilities Did Not
Comply or May Not Have Complied With Terms and
A-05-22-00012 6/9/2025
Conditions and Federal Requirements for Expending
Provider Relief Fund Payments
Selected Home Health Agencies Complied With Terms
and Conditions and Federal Requirements for Provider A-01-22-00503 11/26/2024
Relief Fund Payments
Seven of Thirty Hospices Reviewed Did Not Comply or
May Not Have Complied With Terms and Conditions
A-02-22-01014 11/8/2024
and Federal Requirements for Provider Relief Fund
Payments
HRSA Made Some Potential Overpayments to
Providers Under the Phase 2 General Distribution of A-09-22-06001 3/4/2024
the Provider Relief Fund Program
The Provider Relief Fund Helped Select Nursing Homes
Maintain Services During the COVID 19 Pandemic, but OEI-06-22-00040 12/12/2023
Some Found Guidance Difficult To Use
HHS’s Oversight of Automatic Provider Relief Fund
Payments Was Generally Effective but Improvements A-02-20-01025 10/30/2023
Could Be Made
HRSA Made COVID-19 Uninsured Program Payments
to Providers on Behalf of Individuals Who Had Health
A-02-21-01013 7/13/2023
Insurance Coverage and for Services Unrelated to
COVID-19
Targeted Provider Relief Funds Allocated to Hospitals
Had Some Differences With Respect to the Ethnicity OEI-05-20-00580 7/12/2023
and Race of Populations Served
HHS’s and HRSA’s Controls Related to Selected
Provider Relief Fund Program Requirements Could Be A-09-21-06001 9/26/2022
Improved
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 14
APPENDIX C: PROVIDER RELIEF FUND GENERAL AND TARGETED DISTRIBUTION PAYMENTS
As of October 2024, HRSA distributed $145.9 billion of the $178 billion appropriated to HHS
under the PRF program. Of the $145.9 billion, $88.4 billion was distributed in General
Distributions and $57.5 billion was distributed in several Targeted Distributions. A portion of
the remaining $32.1 billion was distributed or allocated for HRSA’s program for uninsured
individuals, the COVID-19 Coverage Assistance Fund, and Phase 4 General Distribution
payments. 33
General Distributions
HRSA made General Distributions in four phases to health care providers, including Medicare
providers; providers participating in Medicaid, Children’s Health Insurance Program (CHIP), or
Medicaid managed care plans; dentists; assisted living facilities; and behavioral health
providers.
• Phase 1 General Distribution: HRSA distributed $48.5 billion to providers in two rounds
under the Phase 1 General Distribution for eligible providers that billed Medicare fee-
for-service. These funds were allocated proportional to providers’ shares of annual
patient service revenues.
• Phase 2 General Distribution: HRSA distributed $5 billion in the Phase 2 General
Distribution to Medicaid, CHIP, and dental providers, as well as assisted living facilities
and certain Medicare providers who did not receive a Phase 1 General Distribution
payment equal to 2 percent of their total patient care revenue or had a change in
ownership in 2019 or 2020. Providers were required to apply for funding and included
in their applications certain financial information related to documenting revenue
necessary to determine the amount that a facility would receive.
• Phase 3 General Distribution: HRSA distributed $19.3 billion in the Phase 3 General
Distribution to providers that had not received funding in prior distributions (i.e.,
because they were new or because they were behavioral health providers not included
in a prior allocation). Providers that had previously received PRF payments but had not
received the full 2 percent of their annual patient revenue in PRF assistance were also
eligible to apply for additional funds. Providers were required to apply for these funds.
• Phase 4 General Distribution: HRSA distributed approximately $15.6 billion in the Phase
4 General Distribution to providers based on changes in revenues and expenses as well
as the amount and type of services provided to Medicare, Medicaid, and CHIP patients.
Providers were required to apply for these funds.
33
As of June 2023, with the passage of the Fiscal Responsibility Act of 2023, P.L. No. 118-5, Congress rescinded
unobligated PRF funds. In response, HRSA stopped making PRF payments to providers.
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 15
Targeted Distributions
HRSA also distributed PRF funds to target certain types of providers that had high needs due to
COVID-19. These included the following:
• COVID-19 High-Impact Area Providers: HRSA distributed nearly $22 billion in COVID-19
high-impact area payments to hospitals that had large numbers of COVID-19 inpatient
admissions.34
• Safety Net Hospitals and Children’s Hospitals: HRSA distributed $13.3 billion to safety
net and acute care hospitals and $1.1 billion to children’s hospitals.
• Rural Providers: HRSA distributed $11.2 billion in rural payments to rural hospitals,
including rural acute care general hospitals and critical access hospitals; rural health
clinics; and Federally Qualified Health Centers located in rural areas, including specialty
rural hospitals, urban hospitals with certain rural Medicare designations, and hospitals
in small metropolitan areas.
• Tribal Hospitals, Clinics, and Urban Health Centers/Indian Health Service Providers: HRSA
distributed $540 million in relief funds to the Tribal hospitals, clinics, and urban health
centers. These payments were based on operating expenses.
• Skilled Nursing Facilities and Nursing Homes: HRSA distributed $4.9 billion in skilled
nursing facility distribution payments. Additionally, to help combat the devastating
effects of COVID-19, HRSA distributed $4.5 billion to skilled nursing facilities and nursing
homes nationwide, which included payments for infection control and quality incentive
payments to nursing homes that created and maintained safe environments for their
residents.
34
Hospitals that treated 100 or more COVID-19 patients between Jan. 1 and Apr. 10, 2020, were eligible for the
first round of high-impact distributions. Hospitals that treated more than 160 COVID-19 patients between Jan. 1
and June 10, 2020, were eligible for the second round of high-impact distributions.
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 16
APPENDIX D: OPTIONS FOR CALCULATING LOST REVENUES
Providers, including dental providers, could use one of the following three options to calculate
their lost revenues.
Lost Revenues
Option 1 Option 2 Option 3
Options
The difference
between actual
patient care
The difference between Any reasonable
revenues from
Definition of Option budgeted and actual method of estimating
2019 and actual
patient care revenues revenues
patient revenues
during the period
of availability
PRF Reporting 2020 Budgeted Alternate Reasonable
2019 Actual Revenue
Portal Option Revenue Methodology
Base Period for
2019 2020 or 2021 Not prescribed
Calculation
Actuals vs. Actuals
Calculation Method (e.g., Q1 2020 vs. Budget vs. Actuals Not prescribed
Q1 2019)
Frequency of
Quarterly Quarterly Quarterly
Calculation
Each quarter during the
Duration of Lost Each quarter during the Each quarter during the period of availability in
Revenues Period period of availability period of availability which lost revenues were
determined
Service Lines To All patient care services
All patient care
Include in All patient care services (as appropriate for
services
Revenues methodology)
Budget Approval
Not applicable Before March 27, 2020 Not prescribed
Date
Source: HRSA, Provider Relief Fund Lost Revenues Guide – Reporting Period 2. Accessed on June 27, 2025.
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 17
APPENDIX E: SELECTED DENTAL PROVIDERS’ REPORTED USE OF PROVIDER RELIEF FUND
PAYMENTS FOR REPORTING PERIODS 2 AND 3
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 18
APPENDIX F: SUMMARY OF SAMPLED DENTAL PROVIDERS’ INACCURATELY CALCULATED AND
REPORTED LOST REVENUE AMOUNTS
Inaccurately
Sample Total PRF Payments Calculated and
Dental Dental Provider Reported Lost
Provider Reported in Periods Revenue Reason for Inaccurately Calculated and
Number 2 and 3 Amount Reported Lost Revenue Amount
1 $2,793,183 $0
2 $1,243,109 $841,905* Used incorrect revenue amounts for 2020
3 $2,756,249 $0
4 $4,009,074 $0
5 $1,641,398 $0
6 $2,687,515 $0
7 $6,103,505 $0
8 $2,040,921 $0
9 $729,013 $0
10 $2,797,105 $0
11 $1,659,922 $0
12 $441,247 $0
13 $14,629,861 $0
14 $11,620,039 $1,587,854* Used incorrect revenue amounts for 2019
15 $5,082,572 $0
16 $4,550,116 $0
17 $15,653,756 $0
18 $1,573,165 $0
19 $1,330,446 $0
20 $849,556 $0
Used incorrect revenue amounts for 2020
21 $1,087,962 $903,090*
and 2021
Revenue adjustments from subsequent
22 $882,499 $48,262*
period corrections for 2020 and 2021
23 $940,000 $0
24 $7,259,156 $0
25 $6,326,349 $0
26 $8,896,124 $0
27 $2,757,768 $0
28 $3,567,889 $0
29 $3,654,126 $0
30 $3,434,173 $0
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 19
Inaccurately
Sample Total PRF Payments Calculated and
Dental Dental Provider Reported Lost
Provider Reported in Periods Revenue Reason for Inaccurately Calculated and
Number 2 and 3 Amount Reported Lost Revenue Amount
Total $122,997,797† $3,381,110†
* We reviewed the dental provider’s total lost revenue calculations for periods 1, 2, and 3, which
exceeded the total PRF payments the dental provider reported for the same periods. These inaccurately
calculated revenues could be used to offset PRF payments in future reporting periods.
† Amounts do not add up to the total due to rounding.
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 20
APPENDIX G: OTHER MATTERS – POTENTIAL SAVINGS CALCULATIONS
(A) (B) (C) (D) (E) (F) (G) (H)
OIG Option Total PRF Total Lost Total PRF Total Lost Recalculated Total Potential
Sample Dental Payments Revenues Dental Payment Revenues Lost Revenues Savings if Dental
Number Providers Dental Providers Dental Remained After if Dental Providers Used
Used To Providers Calculated and Providers Reporting Providers Used Option 1 and
Calculate Reported in Reported Applied To Periods 2 and 3 Option 1 and Annualized Loss
Lost Periods 2 and 3 Offset Lost Annualized Loss Calculation
Revenues Revenues in (D) - (E) = (F) Calculation
(1, 2, 3, Periods 1, 2, (D) - (G) = (H)
or N/A) and 3
1 1 $2,793,183 $31,556,225 $2,793,183 $28,763,042 $30,903,149 $653,076
2 3 $1,243,109 $12,608,490 $1,243,109 $11,365,381 $22,171,571 $0
3 1 $2,756,249 $19,162,190 $2,756,249 $16,405,941 $14,102,538 $5,059,652
4 1 $4,009,074 $9,454,034 $2,768,461 $6,685,573 $7,815,698 $1,638,337
5 3 $1,641,398 $5,559,629 $1,400,659 $4,158,970 $5,559,626 $3
6 N/A $2,687,515 N/A N/A N/A N/A N/A
7 N/A $6,103,505 N/A N/A N/A N/A N/A
8 N/A $2,040,921 N/A N/A N/A N/A N/A
9 N/A $729,013 N/A N/A N/A N/A N/A
10 1 $2,797,105 $4,955,144 $2,247,629 $2,707,515 $0 $4,955,144
11 1 $1,659,922 $8,523,021 $1,464,111 $7,058,910 $9,324,600 $0
12 1 $441,247 $1,892,758 $441,247 $1,451,511 $1,800,525 $92,234
13 N/A $14,629,861 N/A N/A N/A N/A N/A
14 1 $11,620,039 $58,627,005 $9,981,470 $48,645,535 $51,104,961 $7,522,044
15 N/A $5,082,572 N/A N/A N/A N/A N/A
16 1 $4,550,116 $9,003,644 $3,274,133 $5,729,511 $3,008,277 $5,995,367
17 N/A $15,653,756 N/A N/A N/A N/A N/A
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 21
(A) (B) (C) (D) (E) (F) (G) (H)
OIG Option Total PRF Total Lost Total PRF Total Lost Recalculated Total Potential
Sample Dental Payments Revenues Dental Payment Revenues Lost Revenues Savings if Dental
Number Providers Dental Providers Dental Remained After if Dental Providers Used
Used To Providers Calculated and Providers Reporting Providers Used Option 1 and
Calculate Reported in Reported Applied To Periods 2 and 3 Option 1 and Annualized Loss
Lost Periods 2 and 3 Offset Lost Annualized Loss Calculation
Revenues Revenues in (D) - (E) = (F) Calculation
(1, 2, 3, Periods 1, 2, (D) - (G) = (H)
or N/A) and 3
18 1 $1,573,165 $6,609,583 $1,422,563 $5,187,020 $5,059,987 $1,549,596
19 3 $1,330,446 $3,546,843 $667,024 $2,879,819 $0 $3,546,843
20 1 $849,556 $3,678,971 $807,821 $2,871,150 $3,678,660 $311
21 1 $1,087,962 $5,184,344 $909,744 $4,274,600 $2,752,335 $2,432,008
22 1 $882,499 $2,966,628 $882,499 $2,084,129 $2,372,345 $594,283
23 N/A $940,000 N/A N/A N/A N/A N/A
24 1 $7,259,156 $28,989,517 $7,259,156 $21,730,361 $28,989,517 $0
25 1 $6,326,349 $82,965,949 $6,326,349 $76,639,600 $87,164,847 $0
26 1 $8,896,124 $22,258,465 $8,896,124 $13,362,341 $9,317,446 $12,941,019
27 1 $2,757,768 $5,600,478 $2,196,179 $3,404,299 $1,527,567 $4,072,911
28 1 $3,567,889 $12,431,441 $2,040,692 $10,390,749 $10,798,675 $1,632,766
29 3 $3,654,126 $7,654,664 $3,202,820 $4,451,844 $4,295,374 $3,359,290
30 3 $3,434,173 $6,151,770 $3,073,992 $3,077,778 $3,219,333 $2,932,438
Total $122,997,797* $349,380,793 $66,055,215* $283,325,579 $304,967,030* $58,977,322
* Amounts do not add up to the total due to rounding.
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 22
APPENDIX H: HEALTH RESOURCES AND SERVICES ADMINISTRATION COMMENTS
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 23
Dental Providers’ Compliance With Provider Relief Fund Requirements (A-02-23-01013) 24
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