Report (2020-03-13)

Full text

OIG.HHS.GOV
February 2026 | A-09-23-01001
Fourteen of Thirty Selected Indian
Health Service and Rural Providers
Did Not Comply or May Not Have
Complied With Terms and
Conditions and Federal
Requirements for Expending
Provider Relief Fund Payments

OIG.HHS.GOV

February 2026 | A-09-23-01001
Fourteen of Thirty Selected Indian Health Service and Rural Providers
Did Not Comply or May Not Have Complied 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.  These funds were distributed 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 Indian Health Service (IHS) and rural providers expended taxpayer funds
in accordance with Federal and program requirements.
What OIG Found
• Of the 30 selected IHS and rural providers we reviewed, 14 providers claimed a total of $70.6 million of
unallowable PRF expenditures, and 2 of those providers also inaccurately calculated or could not
support $19.7 million of lost revenues.  These 14 providers received a total of $570.8 million in PRF
payments.  The remaining 16 providers used PRF payments for allowable expenditures and lost
revenues.
• These deficiencies occurred because although providers attested to the PRF terms and conditions and
HRSA provided continuously updated guidance to PRF recipients, some providers made clerical errors
in their reporting of expenditures and did not always correctly interpret HRSA guidance or maintain
documentation to support reported expenditures.
What OIG Recommends
We made three recommendations to HRSA, including that it require the selected providers to return any
unallowable expenditures and lost revenue amounts to the Federal Government or ensure that the providers
properly replace these unallowable expenditures with unreimbursed lost revenues or eligible expenses.  The
full recommendations are in the report.  HRSA concurred with our recommendations.

IHS Facilities’ and Rural Providers’ Compliance With Provider Relief Fund Requirements (A-09-23-01001)
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 IHS and Rural Providers That Received Provider Relief Fund
   Payments .............................................................................................................. 4

How We Conducted This Audit ........................................................................................... 6

FINDINGS ......................................................................................................................................... 7

Some IHS and Rural Providers Used Provider Relief Fund Payments for Unallowable
   Expenditures and Inaccurately Calculated or Unsupported Lost Revenues .................... 8
Salary Costs Exceeded the Federal Executive Level II Salary Limit ......................... 8
Costs Not Adequately Supported ........................................................................... 8
Unallowable Costs ................................................................................................... 9
Costs Charged but Not Incurred ........................................................................... 10
Costs or Losses Reimbursed or Obligated To Be Reimbursed by Other
   Funding Sources ................................................................................................. 10
Duplicate Expenses ............................................................................................... 11
Inaccurate or Unsupported Lost Revenue Calculations  ...................................... 11

Some Selected Providers Used Provider Relief Fund Payments for Potentially
   Unallowable Expenditures ............................................................................................. 12

Causes of Unallowable and Potentially Unallowable Expenditures and Inaccurately
   Calculated or Unsupported Lost Revenues .................................................................... 13

RECOMMENDATIONS ................................................................................................................... 13

OTHER MATTERS ........................................................................................................................... 14

HEALTH RESOURCES AND SERVICES ADMINISTRATION COMMENTS AND OFFICE OF
   INSPECTOR GENERAL RESPONSE ............................................................................................... 15

IHS Facilities’ and Rural Providers’ Compliance With Provider Relief Fund Requirements (A-09-23-01001)
APPENDICES

A: Audit Scope and Methodology ..................................................................................... 16

B: Related Office of Inspector General Reports ................................................................ 19

C: Provider Relief Fund General and Targeted Distribution Payments ............................ 20

D: Options for Calculating Lost Revenues ......................................................................... 22

E: Selected IHS and Rural Providers’ Reported Use of Provider Relief Fund
       Payments for Our Audit Period .................................................................................. 23

F: Summary of Sampled IHS and Rural Providers’ Unallowable Expenditures
       and Inaccurately Calculated Lost Revenue Amounts ................................................. 24

G: Other Matters – Potential Savings Calculations ........................................................... 26

H: Health Resources and Services Administration Comments ......................................... 28

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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, 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 Indian Health Service (IHS) facilities’ and rural providers’
compliance with terms and conditions and Federal requirements for expending PRF payments.4
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.

4 In this report, we refer to IHS facilities and rural providers as “IHS and rural providers.”

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OBJECTIVE

Our objective was to determine whether selected IHS and rural 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.5
Providers throughout the Nation reported that ceasing elective procedures and other services
decreased revenues while their costs increased as they prepared for a potential surge of
patients.6  Many providers reported that their cash reserves were quickly depleted, which could
have disrupted ongoing hospital operations.  Additionally, providers—especially rural
hospitals—requested financial assistance, including loans and grants.  Smaller, independent
hospitals, such as rural hospitals and Critical Access Hospitals, reported that they were at
greater financial risk than those in larger systems and faced more financial uncertainty.

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-19.7
HHS received a combined $178 billion in funding, of which $145.9 billion was distributed via PRF
payments to providers.8  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.

5 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.

6 OIG, Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23–
27, 2020 (OEI-06-20-00300), Apr. 3, 2020.

7 Providers had up to the end of the quarter in which the public health emergency ended (June 30, 2023) to use
PRF payments for lost revenues attributable to COVID-19.

8 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 is not part of the PRF.

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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

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COVID-19.  Within HHS, HRSA was responsible for providing day-to-day oversight and managed
all aspects of the PRF program.9

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.10  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 IHS and Rural Providers That Received Provider Relief Fund Payments

IHS facilities fall into two categories: (1) facilities operated by IHS and (2) IHS-funded facilities
operated by federally recognized Indian Tribes.  Both provide medical and public health services
primarily to American Indians and Alaska Natives who are members of federally recognized
Tribes.  Rural providers provide care in rural or underserved areas in the Nation.  Providers,
including IHS and rural providers, may have been eligible to receive PRF payments from
multiple distributions.  For example, a provider could have received PRF payments through the
General Distribution as well as the Targeted Distribution for high-impact areas and rural
providers.11, 12  IHS and rural 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, these 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).

9 HHS and HRSA, PRF General & Targeted Distribution Cycle Memo, dated Sept. 30, 2020, and Sept. 30, 2021.

10 HRSA, Provider Relief Programs: Provider Relief Fund and ARP Rural Payments Frequently Asked Questions (PRF
FAQs).  Accessed on July 23, 2025.  HRSA, Provider Relief Fund Distributions and American Rescue Plan Rural
Distribution Post-Payment Notice of Reporting Requirements (PRF Reporting Requirements).  Accessed on July 23,
2025.

11 PRF payments were distributed to providers based on providers’ taxpayer identification numbers (TINs).
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 1 and 2 covered PRF payments received during CY 2020.  An IHS or rural
provider 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 organizations (e.g.,
individual hospitals).  An IHS or rural provider reporting entity may be a stand-alone hospital, a hospital group, or a
parent organization.

12 For details on General and Targeted Distribution payments, see Appendix C.  In addition to PRF payments, IHS
and rural 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 from grants and donations from other local and State governments or private sources.

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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
expenses or lost revenues (i.e., patient care revenues) attributable to COVID-19;13 (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).14

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.15  Providers, including IHS and rural providers, were required to
report on their use of PRF payments in broad categories (i.e., lost revenue, health care-related
expenses, or general and administrative expenses).  For expenses, IHS and rural providers were
required to report on their use of PRF payments for health care-related expenses (e.g.,
expenses for purchasing equipment such as ventilators 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).16  IHS and rural 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.17

For lost revenues, IHS and rural 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

13 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.

14 Recipients were not allowed to use PRF payments to pay any salary at a rate in excess of Executive Level II, which
was set at $197,300 for 2020 and $199,300 for 2021.

15 HRSA required all providers that received PRF payments exceeding $10,000 in the aggregate during any given
payment-received period (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.

16 HRSA, PRF Reporting Requirements.

17 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.

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2. The difference between budgeted patient care revenues (approved by the providers’
officials prior to March 27, 2020) and actual patient care revenues

3. Any reasonable method of estimating revenues18

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 are not required to return PRF payments used for unallowable
purposes (e.g., lobbying) to the Federal Government if they have 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 nearly $1.56 billion in PRF payments to a nonstatistical sample of 30 IHS and
rural provider taxpayer identification numbers (TINs) during the period from April 10, 2020,
through June 30, 2021 (audit period) that reported lost revenues and expenditures.  (We refer
to these sample units throughout the report as “providers.”)19  The selected providers reported
that they used $1 billion of their PRF payments to offset lost revenues, $376.2 million for
general and administrative expenses, and the remaining $142.7 million for health care-related
expenses.20  Appendix E contains details on how the selected providers used PRF payments
issued for our audit period.

We selected the providers based on an analysis that considered the amount of PRF payments
received, geographic location (i.e., States with a high percentage of rural populations), and
organizational structure (e.g., parent companies and subsidiary organizations).21  We reviewed

18 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).

19 The sampling frame consisted of 4,516 IHS and rural providers that received and kept 1 or more PRF payments
totaling approximately $25.2 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 IHS and rural
providers that received PRF payments issued from Apr. 10, 2020, through June 30, 2021, and for which providers
attested to the payment terms and conditions or were deemed to have accepted the terms and conditions.

20 The sampled providers reported these amounts on expenditure reports submitted to HRSA for reporting periods
1, 2, and 3.  The amounts total to less than the $1.56 billion due to rounding.

21 Our sample unit was an IHS or a rural provider that reported the use of PRF General and Targeted Distribution
payments.  Each sampled provider could have been an IHS facility, a rural provider, or part of a parent-subsidiary
system that may have included a parent company and various provider types (e.g., hospitals, clinics, urgent care
facilities, and physician groups).  The 30 sampled providers each received more than $5 million in PRF payments
during our audit period and were located in 20 States.  Two of the sampled providers were IHS facilities and
28 were part of rural provider systems that included hospitals.

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the providers’ PRF payments used to offset lost patient care revenues or cover general and
administrative and health care-related expenses.  Specifically, for each of the selected 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 providers that reported lost revenues, we reviewed the providers’ lost revenue
calculations.22

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 providers, 16 used the funds for allowable general and administrative and
health care-related expenses and to offset lost revenues attributable to COVID-19.  However,
the remaining 14 providers did not comply or may not have complied with Federal
requirements.  Specifically, 12 providers used PRF payments for unallowable expenditures, and
2 of these providers also inaccurately calculated or could not support their lost revenues.  In
addition, 2 of the 14 providers used PRF payments for potentially unallowable expenditures.
These deficiencies occurred because although providers attested to the PRF terms and
conditions and HRSA provided continuously updated guidance to PRF recipients, some
providers made clerical errors in their reporting of expenditures and did not always correctly
interpret HRSA guidance or maintain documentation to support reported expenditures.

As a result of these deficiencies, 14 of the 30 selected providers used PRF payments for
unallowable expenditures totaling $70.6 million and inaccurately calculated or could not
support lost revenues totaling $19.7 million.23  In addition, 2 of the 14 selected providers used
PRF payments for $382,656 in expenditures that may not have been supported or allowable.
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 providers.

22 Of the 30 providers, 20 providers reported both expenses and lost revenues, 7 providers reported only lost
revenues, and 3 providers reported only expenses.

23 Unallowable expenditures totaled $70,590,911, and inaccurately calculated or unsupported lost revenues
totaled $19,709,036.

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SOME IHS AND RURAL PROVIDERS USED PROVIDER RELIEF FUND PAYMENTS FOR
UNALLOWABLE EXPENDITURES AND INACCURATELY CALCULATED OR UNSUPPORTED LOST
REVENUES

Salary Costs Exceeded the Federal Executive Level II Salary Limit

The PRF terms and conditions specified that PRF recipients could not use PRF payments to
pay the salary of an individual at a rate in excess of Executive Level II salary levels.24  The
Federal Executive Level II salary level was $197,300 in calendar year (CY) 2020 and $199,300
in CY 2021.

Four providers used PRF payments for salaries for executives and other employees that
exceeded the Executive Level II salary levels for CYs 2020 and 2021 by a total of $1.2 million.
Specifically:

• Two providers used PRF payments for salaries for 49 executives and other employees
that exceeded the Executive Level II salary levels for CYs 2020 or 2021 by a total of
$900,921.  The providers used PRF payments to cover salary costs for certain executives
and employees based on a methodology tied to the percentage of time allocated to
support actions related to COVID-19 and non-COVID-19.

• One provider used PRF payments to cover salary and fringe benefit costs for 21
executives and medical professionals that exceeded the Executive Level II salary levels
for CYs 2020 and 2021 by a total of $328,981.25

• One provider used PRF payments to cover salary costs and fringe benefits for two
employees whose salaries exceeded the Executive Level II threshold for CY 2020 by a
total of $5,092.

Costs Not Adequately Supported

PRF recipients must comply with certain Uniform Administrative Requirements, Cost Principles,
and Audit Requirements for HHS Awards (45 CFR part 75).  The financial management system of
each PRF recipient must provide accurate, current, and complete disclosure of the financial
results of each Federal award or program.  The PRF recipient’s records must identify the source
and application of funds for federally funded activities and be supported by source
documentation (45 CFR §§ 75.302(b)(2) and (3)).

24 PRF terms and conditions for General and Targeted Distribution payments.

25 For example, the provider used PRF funds to pay the salary of its Chief Executive Officer (CEO)—1 of the 21
executives or medical professionals.  Based on an annual salary amount of $600,000 for CY 2020, the CEO’s
biweekly pay amount was $25,900.  This amount was charged to the PRF for the pay period ending Apr. 26, 2020.
If the provider based its calculation on the Federal Executive Level II limit for 2020, which was $197,300, the CEO’s
biweekly pay amount charged to PRF would have been $7,588 instead of the $25,900.

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Three providers did not maintain documentation to support the use of PRF payments to
cover lab testing, salary, and other expenses, totaling $10.3 million.  Specifically:

• One provider used PRF payments totaling $7.1 million for salaries and other expenses
and provided forms indicating that the expenses were reclassified from one account to
another account (e.g., from a Medicaid expense account to a COVID-19-related expense
account).  The provider did not furnish supporting documentation (e.g., a list of
transactions or invoices) for the expenses.

• One provider used PRF payments of $1.8 million for lab testing expenses and $22,453
for salaries and wages; however, the provider did not furnish any supporting
documentation for lab testing expenses or detailed information (e.g., specific dates of
the expenses) for its salaries and wages.

• One provider stated that it had intended to remove $1.4 million in expenses for COVID-
19 testing in a subsequent reporting period and did not provide documentation to
support the expenses.26

Unallowable Costs

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 for purposes related to COVID-19 (e.g., expenses paid for purchasing equipment
such as ventilators and sanitizing equipment to prevent, prepare for, or respond to COVID-19),
(2) applied to offset eligible lost revenues attributable to COVID-19 (e.g., lost patient care
revenue), (3) not duplicated by other funding sources, and (4) not used to reimburse salaries in
excess of a certain threshold or to pay for certain prohibited activities (e.g., lobbying).

Two providers used PRF payments totaling $36 million for expenses not related to COVID-19
and other expenses.  Specifically, one provider reported to HRSA on its expenditure report
that it used PRF payments of $35.2 million for expenses (e.g., personnel and general
administration expenses) that, according to the provider, were not used for purposes related
to COVID-19.27  The other provider reported that it used PRF payments of $749,640 for an
equipment rental expense unrelated to COVID-19 ($26,200) and for accrued bonuses instead
of actual bonuses paid ($723,440).

26 We did not confirm whether the provider removed the expenses for COVID-19 testing in a subsequent reporting
period because that reporting period was outside the scope of our audit.

27 The provider stated that it “attempted to enter lost revenue only and were told by HRSA hotline professionals
that we had to enter expenses for the period and that [we] could not enter lost revenue alone.”

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Costs Charged but Not Incurred

PRF recipients must comply with certain Uniform Administrative Requirements, Cost Principles,
and Audit Requirements for HHS Awards (45 CFR part 75).  The financial management system of
each PRF recipient must provide accurate, current, and complete disclosure of the financial
results of each Federal award or program.  The PRF recipient’s records must identify the source
and application of funds for federally funded activities and be supported by source
documentation (45 CFR §§ 75.302(b)(2) and (3)).  PRF recipients must only use payments for
eligible expenses, including services rendered and lost revenues (up to the end of the public
health emergency), during the period of availability.28

Two providers used PRF payments totaling $1.9 million for expenses that were charged but not
actually incurred during the period of availability.  Specifically, one provider used PRF payments
for unemployment insurance expenses totaling $1.5 million that were forgiven by the State and
$57,200 for canceled drug orders.  The other provider reported $317,757 in PRF payments for
expenses not incurred during the period of availability.29

Costs or Losses Reimbursed or Obligated To Be Reimbursed by Other Funding Sources

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 not used to reimburse expenses or losses that had been reimbursed from other sources or
had been obligated to be reimbursed by other sources.30

Six providers used PRF payments for expenses or lost revenues, totaling $20.4 million, that
were reimbursed or obligated to be reimbursed by other sources.  Specifically:

• One selected provider used PRF payments for lost revenues totaling $19.7 million;
however, the lost revenues were obligated to be reimbursed by other sources.31

28 The period of availability of funds is based on the date the payment is received.  HRSA, Provider Relief Fund
General and Targeted Distributions Post-Payment Notice of Reporting Requirements, Jun. 11, 2021.

29 The provider did not return to the Federal Government the $317,757 and stated that it had additional expenses
after the period of availability.  For example, the supporting documentation showed that the provider incurred
charges in September 2022; however, these expenses were not incurred during the period of availability
(Jan. 1, 2020, through Dec. 31, 2021).

30 Coronavirus Aid, Relief, and Economic Security Act, P.L. No. 116-136 (Mar. 27, 2020); PRF terms and conditions
for General and Targeted Distribution payments.

31 The provider received funds from other Federal funding sources that were allocated for the reimbursement for
lost revenues.

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• Four other providers used PRF payments for expenses that were also reimbursed by
other Federal funding sources (e.g., Medicare or the Federal Emergency Management
Agency) totaling $614,781.

• One provider used PRF payments for expenses that were also reimbursed by a non-
Federal funding source totaling $26,896.

Duplicate Expenses

PRF recipients must comply with certain Uniform Administrative Requirements, Cost Principles,
and Audit Requirements for HHS Awards (45 CFR part 75).  The financial management system of
each PRF recipient must provide accurate, current, and complete disclosure of the financial
results of each Federal award or program.  The PRF recipient’s records must identify the source
and application of funds for federally funded activities and be supported by source
documentation (45 CFR §§ 75.302(b)(2) and (3)).  Additionally, PRF payments may not be
applied to the same expenses and lost revenues that were reported on in prior reporting
periods.32

Four providers used PRF payments to cover duplicate expenses totaling $765,562.  Specifically:

• Two providers used PRF payments to cover salary costs, totaling $400,516, that were
already reported in the same period.

• One provider used PRF payments to cover two payments for the same equipment,
totaling $26,318, that were already reported in the same period.

• One provider used PRF payments to cover expenses for in-house and contracted lab
services, totaling $338,728, that it already reported in a prior reporting period.

Inaccurate or Unsupported Lost Revenue Calculations

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 2019 actual patient care revenues and
actual patient care revenues during the period of availability.33, 34  In addition, HRSA’s guidance
for lost revenue calculations provided recipients flexibility in the reconciliation of lost revenues
among parent entities and their subsidiaries organizations.  However, HRSA’s FAQs stated that

32 HRSA, PRF FAQs.

33 HRSA, PRF Reporting Requirements.

34 HRSA, “How to Calculate Lost Revenues for PRF and ARP Rural Reporting.”  Accessed on July 25, 2025.

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expenses and lost revenues may not be duplicated, and payments may not be applied to the
same expenses and lost revenues that were reported in prior reporting periods.

Two providers inaccurately calculated lost revenues or could not support lost revenue
calculations totaling $19.7 million.  Specifically, one provider incorrectly excluded expenses that
offset patient revenue, resulting in $8.2 million in overstated lost revenues.  The other provider
could not support its lost revenue calculation totaling $11.5 million.  According to the provider,
it did not maintain supporting documentation after undergoing a “substantial information
technology update.”

SOME SELECTED PROVIDERS USED PROVIDER RELIEF FUND PAYMENTS FOR POTENTIALLY
UNALLOWABLE EXPENDITURES

PRF recipients must comply with certain Uniform Administrative Requirements, Cost Principles,
and Audit Requirements for HHS Awards (45 CFR part 75).  The financial management system of
each PRF recipient must provide accurate, current, and complete disclosure of the financial
results of each Federal award or program.  The PRF recipient’s records must identify the source
and application of funds for federally funded activities and be supported by source
documentation (45 CFR §§ 75.302(b)(2) and (3)).

Two providers used PRF payments to cover expenses, totaling $382,656, that may have been
unallowable because the expenses were not fully supported or reimbursed by other funding
sources.  Specifically:

• One provider used PRF payments to cover salary expenses totaling $328,174 for which a
portion may have been unallowable.  The provider submitted documentation to support
some of the expenses that we tested; however, the provider did not provide
documentation for other expenses.35

• One provider used PRF payments for Critical Access Hospital expenses totaling $54,482
that may have been reimbursed by Medicare.36

35 Because we could not test all of these expenses, we concluded that a portion of these expenditures may have
been unallowable.

36 Medicare pays Critical Access Hospitals for most services provided to patients at 101 percent of reasonable
costs.  HRSA’s PRF FAQs state that a payment to a provider based on the provider’s Medicare cost is considered to
fully reimburse the provider for the costs associated with providing care to Medicare patients, and no money from
the PRF would be available for those identified Medicare costs.  The selected provider did not adjust its reported
PRF expenses for any expenses related to its reimbursed Critical Access Hospital costs.

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CAUSES OF UNALLOWABLE AND POTENTIALLY UNALLOWABLE EXPENDITURES
AND INACCURATELY CALCULATED OR UNSUPPORTED LOST REVENUES

These deficiencies occurred because although providers attested to the PRF terms and
conditions and HRSA provided continuously updated guidance to PRF recipients, the providers
made clerical errors in their reporting of expenditures.  In addition, the providers did not always
correctly interpret HRSA guidance or maintain documentation to support reported
expenditures.

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 providers indicated that they experienced staff turnover and had issues entering
information in HRSA’s PRF Reporting Portal.  These and other unprecedented challenges of the
pandemic may have contributed to clerical errors when providers reported PRF expenditures or
may have caused staff to misinterpret HRSA’s guidance.

In addition to the recommendations 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.

RECOMMENDATIONS

• We recommend that HRSA require the 12 providers that we determined as having used
PRF payments for unallowable expenditures totaling $70,590,911 to return the
unallowable amounts to the Federal Government or ensure that the providers properly
replace the unallowable expenditures with allowable unreimbursed lost revenues or
eligible expenses, if any.

• We recommend that HRSA require the two providers that we determined as having
inaccurately calculated and reported lost revenues totaling $19,709,036 to identify and
return to the Federal Government any PRF payments inappropriately used to offset lost
revenues or replace the amounts with allowable unreimbursed lost revenues or eligible
expenses, if any.

• We recommend that HRSA work with the two providers that we identified as having
used PRF payments totaling $382,656 for expenditures that may have been unallowable
to determine which amounts should have been allocated and require the providers to
return unallowable amounts to the Federal Government or ensure that the providers
properly replace these unallowable expenditures with unreimbursed lost revenues or
eligible expenses, if any.

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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 the provider
officials before March 27, 2020) and actual patient care revenues

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.37  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-seven of the thirty selected providers reported lost revenues totaling $2.3 billion.  For
these providers, we recalculated 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
actual patient care revenues for 2020, 2021, and the first two quarters of 2022, as applicable).38
If HRSA had required reporting entities to use option 1 and annualize their revenues instead of
allowing stand-alone quarterly calculations, 27 of the 30 selected providers would not have
been able to report a total of $1.5 billion in lost revenues and would not have been able to
apply PRF payments to offset this amount.  For any PRF payments applied against these excess
lost revenue amounts, the PRF payments could have been used for other purposes that
supported 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.

37 HRSA, PRF FAQs.

38 The PRF expenditure reports for the payment period ending June 30, 2020, were due on Sept. 30, 2021, with a
grace period ending on Nov. 30, 2021.  The expenditure reports for the payment period ending Dec. 31, 2020,
were due on Mar. 31, 2022.  Therefore, actual patient care revenues for CY 2020 would have been available before
the PRF report due dates.

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HEALTH RESOURCES AND SERVICES ADMINISTRATION COMMENTS AND
OFFICE OF INSPECTOR GENERAL RESPONSE

In written comments on our draft report, HRSA concurred with our recommendations 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.

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APPENDIX A: AUDIT SCOPE AND METHODOLOGY

SCOPE

We identified 4,516 IHS and rural providers that received and kept 1 or more PRF payments
totaling approximately $25.2 billion.  We selected for audit a nonstatistical sample of 30 IHS
and rural providers (providers) that received PRF payments from General and certain Targeted
Distributions from April 10, 2020, through June 30, 2021, totaling $1.56 billion.39  We selected
providers based on a risk analysis that included geographic location (i.e., States with a high
percentage of rural populations), total PRF payment amounts, and organizational structure
(providers with a parent and subsidiary organization relationship).  We reviewed the selected
providers’ use of PRF payments received from General and certain Targeted Distributions.

We limited our review of HRSA’s and the selected providers’ internal controls to those
applicable to our audit objective.  We did not assess HRSA’s or the 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 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 IHS and rural providers through
HRSA’s PRF Reporting Portal.

We conducted our audit from February 2023 through December 2025.

METHODOLOGY

We took the following steps to accomplish our objective:

• 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

39 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 IHS and rural providers that received PRF payments from
Apr. 10, 2020, through June 30, 2021 (first three periods for which providers received General and certain Targeted
Distribution funds), for which the providers attested to the payment terms and conditions or were deemed to have
accepted the terms and conditions.

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• Obtained PRF payments data for General and Targeted Distributions

• Created a list of IHS and rural providers that received PRF payments from General
Distributions and certain Targeted Distributions40

• Selected a nonstatistical sample of 30 IHS and rural providers that received PRF
payments based on the amount of PRF payments received, geographic locations (States
with a high percentage of urban and rural areas), and organizational structure (providers
with a parent and subsidiary organization relationship)41

• For each selected provider, interviewed IHS and rural provider officials; 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 calculated42

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)

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

40 We obtained from HRSA lists of TINs associated with IHS and rural providers that received PRF payments from
the Targeted Distributions.  We then extracted PRF payments (from the General and Targeted Distributions) for
these TINs from the PRF payments attestation file provided by OIG’s Division of Data Analytics.

41 The sampling frame consisted of 4,516 IHS and rural providers that received and kept 1 or more PRF payments
totaling approximately $25.2 billion.

42 We recalculated lost revenue amounts using the same option that the entity used for determining lost revenues.

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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.

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APPENDIX B: RELATED OFFICE OF INSPECTOR GENERAL REPORTS

Report Title
Report Number
Date
Issued
Nine of Thirty Selected Assisted Living Facilities Did Not
Comply With Terms and Conditions and Federal
Requirements for Expending Provider Relief Fund Payments
A-02-23-01012
12/17/2025
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
11/25/2025
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
9/19/2025
Eleven of Thirty Selected Hospitals Did Not Comply With
Terms and Conditions and Federal Requirements for
Expending Provider Relief Fund Payments
A-02-22-01003
6/11/2025
Ten of Thirty Selected Nursing Facilities Did Not Comply or
May Not Have Complied With Terms and Conditions and
Federal Requirements for Expending Provider Relief Fund
Payments
A-05-22-00012
6/9/2025
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

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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.43

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 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.

43 As of 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.

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Targeted Distributions

HRSA also distributed PRF funds to 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.44

• 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 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.

44 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.

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APPENDIX D: OPTIONS FOR CALCULATING LOST REVENUES

Providers could use one of the following options to calculate their lost revenues.

Lost Revenues
Options
Option 1
Option 2
Option 3
Definition of Option
The difference
between actual
patient care
revenues from
2019 and actual
patient care
revenues during
the period of
availability
The difference between
budgeted and actual
patient care revenues
Any reasonable
method of estimating
revenues
PRF Reporting
Portal Option
2019 Actual Revenue
2020 Budgeted
Revenue
Alternate Reasonable
Methodology
Base Period for
Calculation
2019
2020 or 2021
Not prescribed
Calculation Method
Actuals vs. Actuals
(e.g., Q1 2020 vs.
Q1 2019)
Budget vs. Actuals
Not prescribed
Frequency of
Calculation
Quarterly
Quarterly
Quarterly
Duration of Lost
Revenues Period
Each quarter during the
period of availability
Each quarter during the
period of availability
Each quarter during the
period of availability in
which lost revenues were
determined
Service Lines To
Include in
Revenues
All patient care services
All patient care
services
All patient care services
(as appropriate for
methodology)
Budget Approval
Date
Not applicable
Before March 27, 2020
Not prescribed
Source: HRSA, Provider Relief Fund Lost Revenues Guide – Reporting Period 1, August 2021.  Accessed on July 22,
2025.

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APPENDIX E: SELECTED IHS AND RURAL PROVIDERS’ REPORTED USE OF PROVIDER RELIEF
FUND PAYMENTS FOR OUR AUDIT PERIOD

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APPENDIX F: SUMMARY OF SAMPLED IHS AND RURAL PROVIDERS’ UNALLOWABLE
EXPENDITURES AND INACCURATELY CALCULATED LOST REVENUE AMOUNTS

Sample
Provider
No.
Total PRF Payments
Provider Reported
in Periods 1, 2,
and 3
Unallowable
Expenditures and
Inaccurately
Calculated or
Unsupported Lost
Revenue Amounts
Reason(s) for Unallowable
Expenditures and Inaccurately
Calculated Lost Revenue Amount
1
$80,988,568
-

2
$174,100,422

3
$90,677,783
-

4
$97,362,961
-

5
$155,062,049
-

6
$91,496,842
-

7
$12,172,242
$1,883,227
Costs not adequately supported
Costs or losses reimbursed or
obligated to be reimbursed by other
funding sources
8
$11,454,600
$11,454,600
Inaccurate or unsupported lost
revenue calculations
9
$10,716,946
-

10
$57,642,599
$657,767
Salary costs exceeded Federal salary
limit
Duplicate expenses
11
$40,114,033
$643,670
Salary costs exceeded Federal salary
limit
Duplicate expenses
12
$74,661,226
$1,532,431
Costs or losses reimbursed or
obligated to be reimbursed by other
funding sources
Costs not adequately supported
13
$10,236,149
-

14
$10,879,289
-

15
$11,542,226
-

16
$8,299,315
-

17
$7,405,803
-

18
$6,619,479
$26,318
Duplicate expenses
19
$6,378,412

$219,182
Costs or losses reimbursed or
obligated to be reimbursed by other
funding sources

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Sample
Provider
No.
Total PRF Payments
Provider Reported
in Periods 1, 2,
and 3
Unallowable
Expenditures and
Inaccurately
Calculated or
Unsupported Lost
Revenue Amounts
Reason(s) for Unallowable
Expenditures and Inaccurately
Calculated Lost Revenue Amount
20
$5,540,536
$27,166
Costs or losses reimbursed or
obligated to be reimbursed by other
funding sources
21
$28,210,563
-

22
$37,723,349
$35,193,718
Unallowable costs
23
$123,492,416
$5,092
Salary costs exceeded Federal salary
limit
24
$122,395,050
-

25
$77,556,873
-

26
$83,084,256
$8,254,436
Inaccurate or unsupported lost
revenue calculations
27
$15,995,513
-
28
$69,864,638
$3,283,393
Unallowable costs
Costs charged but not incurred
Duplicate expenses
Costs or losses reimbursed or
obligated to be reimbursed by other
funding sources
Salary costs exceeded Federal salary
limit
29
$19,741,648
$19,741,648
Costs or losses reimbursed or
obligated to be reimbursed by other
funding sources
30
$22,323,451
$7,377,299
Costs charged but not incurred
Costs not adequately supported
Total
$1,563,739,237
$90,299,947

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APPENDIX G: OTHER MATTERS – POTENTIAL SAVINGS CALCULATIONS

(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
OIG
Sample
Number
Option
Providers
Used To
Calculate
Lost
Revenues
(1, 2, 3,
or NA)
Total PRF
Payments
Providers
Reported in
Periods 1, 2, and 3
Total Lost
Revenues Providers
Calculated and
Reported
Total PRF
Payment
Providers
Applied To
Offset Lost
Revenues in
Periods 1, 2,
and 3
Total Lost
Revenues
Remained After
Reporting Periods
1, 2, and 3

(D) - (E) = (F)
Recalculated
Lost Revenues if
Providers Used
Option 1 and
Annualized Loss
Calculation
Total Potential
Savings if
Providers Used
Option 1 and
Annualized Loss
Calculation

(D) - (G) = (H)
1
3
$80,988,568
 $80,988,568
$80,988,568
 $0
$69,539,115
 $11,449,453
2
3
$174,100,422
 $470,524,331
$126,714,156
 $343,810,175
$0
 $470,524,331
3
 3
$90,677,783
 $114,040,898
$90,677,783
 $23,363,115
$0
 $114,040,898
4
 3
$97,362,961
 $100,232,921
$97,362,961
 $2,869,960
NA*
 NA
5
3
$155,062,049
 $348,066,339
$125,513,812
 $222,552,527
$108,057,467
 $240,008,872
6
3
$91,496,842
 $162,992,119
 $91,496,842
 $71,495,277
$35,913,416
 $127,078,703
7
3
$12,172,242
 $18,083,408
 $9,609,626
 $8,473,782
$6,733,496
 $11,349,912
8
3
$11,454,600
 $20,158,143
 $11,454,600
 $8,703,543
$20,158,143
$0
9
1
$10,716,946
 $17,700,089
 $9,032,028
 $8,668,061
$20,119,379
$(2,419,290)
10
3
$57,642,599
 $83,710,019
 $39,896,042
 $43,813,977
$0
 $83,710,019
11
NA
$40,114,033
Did not use PRF to
offset lost revenues
NA
 NA
NA
 NA
12
3
$74,661,226
 $118,338,382
 $72,080,530
 $46,257,852
$218,787,677
 $(100,449,295)
13
1
$10,236,149
 $7,601,213
 $4,030,307
 $3,570,906
$7,399,788
$201,425
14
3
$10,879,289
 $8,156,394
 $7,839,548
 $316,846
$5,299,526
 $2,856,868
15
3
$11,542,226
 $7,574,525
 $6,474,654
 $1,099,871
$2,280,831
 $5,293,694
16
1
$8,299,315
 $2,928,621
 $2,928,621
$0
$0
$2,928,621
17
3
$7,405,803
 $7,036,782
 $6,348,109
$688,673
$0
 $7,036,782

IHS Facilities’ and Rural Providers’ Compliance With Provider Relief Fund Requirements (A-09-23-01001)
27
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
OIG
Sample
Number
Option
Providers
Used To
Calculate
Lost
Revenues
(1, 2, 3,
or NA)
Total PRF
Payments
Providers
Reported in
Periods 1, 2, and 3
Total Lost
Revenues Providers
Calculated and
Reported
Total PRF
Payment
Providers
Applied To
Offset Lost
Revenues in
Periods 1, 2,
and 3
Total Lost
Revenues
Remained After
Reporting Periods
1, 2, and 3

(D) - (E) = (F)
Recalculated
Lost Revenues if
Providers Used
Option 1 and
Annualized Loss
Calculation
Total Potential
Savings if
Providers Used
Option 1 and
Annualized Loss
Calculation

(D) - (G) = (H)
18
3
$6,619,479
 $3,041,434
 $3,041,434
$0
$4,126,126
 $(1,084,692)
19
2
$6,378,412
 $5,749,114
 $5,749,114
 $0
$0
 $5,749,114
20
2
$5,540,536
 $2,414,325
 $1,828,528
 $585,797
$0
 $2,414,325
21
3
$28,210,563
 $31,633,455
 $28,210,563
 $3,422,892
 $27,166,742
 $4,466,713
22
3
$37,723,349
 $56,784,296
 $2,529,631
 $54,254,665
$24,855,659
 $31,928,637
23
3
$123,492,416
 $282,191,134
 $97,165,421
 $185,025,713
$88,764,621
 $193,426,513
24
NA
$122,395,050
Did not use PRF to
offset lost revenues
NA
 NA
NA
 NA
25
3
$77,556,873
 $161,252,296
 $19,832,052
 $141,420,244
$7,086,309
 $154,165,987
26
1
$83,084,256
 $64,231,264
 $61,625,202
 $2,606,062
 $34,282,868
 $29,948,396
27
3
$15,995,513
 $18,914,404
 $15,995,513
 $2,918,891
$0
 $18,914,404
28
3
$69,864,638
 $85,906,733
 $6,639,813
 $79,266,920
$0
 $85,906,733
29
1
$19,741,648
 $29,415,448
 $19,741,648
 $9,673,800
$23,050,309
 $6,365,139
30
NA
$22,323,451
Did not use PRF to
offset lost revenues
NA
 NA
 NA
 NA
Total

$1,563,739,237
$2,309,666,655
$1,044,807,106
$1,264,859,549
$703,621,472
$1,505,812,262
*We did not recalculate the annualized lost revenue under option 1 because the sample item was a parent company that derived its lost revenue based on its
subsidiaries using option 3.  A recalculation would not result in a meaningful comparison or be consistent with the other recalculations.

IHS Facilities’ and Rural Providers’ Compliance With Provider Relief Fund Requirements (A-09-23-01001)
28
APPENDIX H: HEALTH RESOURCES AND SERVICES ADMINISTRATION COMMENTS

IHS Facilities’ and Rural Providers’ Compliance With Provider Relief Fund Requirements (A-09-23-01001)
29

IHS Facilities’ and Rural Providers’ Compliance With Provider Relief Fund Requirements (A-09-23-01001)
30

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