COVID-19 Provider Relief Fund Payment Recovery (GAO, 2023)
Cited in: Provider Relief Fund: The Formula That Paid Medicare First
Full text
United States Government Accountability Office
Report to Congressional Committees
COVID-19
September 2023
PROVIDER RELIEF
FUND
HRSA Continues to
Recover Remaining
Payments Due from
Providers
GAO-23-106083
September 2023
COVID-19 PROVIDER RELIEF FUND
HRSA Continues to Recover Remaining Payments
Due from Providers
Highlights of GAO-23-106083, a report to
congressional committees
Why GAO Did This Study What GAO Found
The PRF was created in March 2020 to The Health Resources and Services Administration (HRSA), an agency within
provide COVID-19 relief to health care the Department of Health and Human Services (HHS), administers and oversees
providers and ensure access to the Provider Relief Fund (PRF). The PRF provided relief to health care providers
essential health care services. for expenses or lost revenues attributable to the COVID-19 pandemic. As of May
Providers included those enrolled in 2023, HRSA distributed $135 billion in payments kept by providers; hospital-
Medicare, Medicaid, and the Children’s based health systems and hospital-affiliated providers received the majority of
Health Insurance Program. payments—about $84 billion. HRSA made payments until June 2023, when the
The CARES Act includes a provision remaining unobligated funds for provider relief payments were rescinded.
for GAO to monitor and report on the
Among its efforts to ensure payment accuracy, HRSA conducted pre-payment
federal response to the COVID-19
reviews to verify provider eligibility and information on provider applications.
pandemic. This report describes (1)
PRF payment distributions; and HRSA also conducted post-payment reviews to check for potential payment
examines (2) efforts to ensure the errors and identify overpayments. HRSA plans to conduct these reviews on 59
accuracy of PRF payments, (3) efforts types of potential payment errors, but the agency has been delayed in
to ensure that PRF payments were completing these reviews. As of May 2023, 21 of 59 remained open. In October
used according to program 2021, GAO recommended that HRSA promptly complete the remaining reviews,
requirements, and (4) the status of but HRSA has not yet implemented the recommendation.
efforts to recover PRF payments. HRSA has taken steps to ensure that providers used PRF payments according to
GAO analyzed data on PRF payments program requirements. HRSA required providers to report on their use of PRF
as of December 2022, by which time payments, and it has been auditing a risk-based sample of providers to verify
nearly all PRF payments had been appropriate use of payments. HRSA also assessed fraud risks and implemented
distributed. GAO analyzed recoveries controls to ensure proper use of payments, though certain processes were only
of PRF payments as of May 2023—the recently implemented. In particular, HRSA implemented recommendations from
most recent data available at the time its 2021 fraud risk assessment. In March 2023, HRSA implemented a process to
of the review. GAO also reviewed review irregular payments and, in June 2023, finalized procedures for responding
information and agency documentation to potential fraud.
on payment integrity activities,
including program reports and risk As of May 2023, HRSA had recovered about half of the $2.62 billion in payments
assessments; interviewed agency identified for recovery. HRSA had established time frames to recover most of the
officials; and compared payment $1.36 billion in payments not yet recovered, but had not established time frames
integrity activities to agency to recover $250 million in remaining overpayments, unused payments, and some
requirements. payments from non-compliant providers. However, in August 2023, HRSA
GAO’s draft report recommended that established time frames for the recovery of these payments.
HRSA establish time frames to Provider Relief Fund (PRF) Payment Recoveries, as of May 2023
promptly recover remaining
overpayments, unused payments and
payments from all noncompliant
providers. In response to the draft
report, in August 2023, HRSA provided
a time frame for the recovery of these
payments. As a result, GAO removed
the recommendation and modified the
report accordingly.
View GAO-23-106083. For more information,
contact Leslie V. Gordon at (202) 512-7114 or
GordonLV@gao.gov.
United States Government Accountability Office
Contents
Letter 1
Background 5
Hospital-Based Health Systems Received the Majority of Provider
Relief Fund Payment Distributions 10
HRSA Reviewed Payments to Ensure Eligibility and Accuracy, but
Has Delayed Completion of Reviews 14
HRSA Has Initiated Audits of Providers’ Reported Use of Relief
Payments and Implemented Its Recommendations to Address
Potential Fraud 19
Over $1 Billion in Provider Relief Fund Payments Remain
Unrecovered 22
Agency Comments 25
Appendix I Comments from the Department of Health and Human Services 29
Appendix II GAO Contact and Staff Acknowledgments 31
Tables
Table 1: Provider Relief Fund General and Targeted Payment
Distributions 7
Table 2: Provider Relief Fund Reporting Deadlines 9
Table 3: Provider Relief Fund (PRF) Payments Kept by Providers,
as of December 2022 11
Table 4: Status of Provider Relief Fund (PRF) Post-Payment
Reviews, as of May 2023 16
Figures
Figure 1: Provider Relief Fund (PRF) Payments Kept by
Providers, by Type of Provider, as of December 2022 12
Figure 2: Provider Relief Fund (PRF) Payments Kept and
Returned by Providers, by Active and Passive Attestation
to Program Requirements, and Rejected Payments, as of
December 2022 13
Figure 3: Application and Automatic Provider Relief Fund (PRF)
Payments, as of December 2022 14
Page i GAO-23-106083 Provider Relief Fund
Figure 4: Status of the Health Resources and Services
Administration (HRSA) Actions to Recover Provider
Relief Fund (PRF) Payments, as of May 2023 23
Abbreviations
HHS Department of Health and Human Services
HRSA Health Resources and Services Administration
OMB Office of Management and Budget
PRF Provider Relief Fund
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Page ii GAO-23-106083 Provider Relief Fund
Letter
441 G St. N.W.
Washington, DC 20548
September 21, 2023
Congressional Committees
The Provider Relief Fund (PRF) was created in March 2020 to ensure
access to essential health care services during the pandemic. As of May
2023, the program provided $135 billion in payments kept by eligible
health care providers for their expenses or losses attributable to the
COVID-19 pandemic. 1 The Health Resources and Services
Administration (HRSA), an agency within the Department of Health and
Human Services (HHS), engaged in an unprecedented effort to quickly
issue PRF payments—distributing more than $92 billion between April
and July 2020. 2 HRSA prioritized distributing PRF payments to providers
as quickly as possible. According to HRSA, this was to compensate
providers for lower revenues from postponed nonessential care and
increased expenses for pandemic supplies. HRSA continued to make
payments to providers until June 2023, when the remaining PRF funds for
provider relief were rescinded. 3
In part due to the risks associated with the rapid distribution of relief
payments, HRSA implemented a number of payment integrity controls to
help ensure that only eligible providers—including those enrolled in
Medicare, Medicaid, and the Children’s Health Insurance Program—
received payments in accurate amounts and that providers used their
1Congress appropriated a total of $178 billion for the PRF as part of the CARES Act,
Paycheck Protection Program and Health Care Enhancement Act, and Consolidated
Appropriations Act, 2021. Pub. L. No. 116-260, div. M, tit. III, 134 Stat. 1182, 1920 (2020);
Pub. L. No. 116-139, div. B, tit. I, 134 Stat. 620, 622 (2020); Pub. L. No. 116-136, div. B,
tit. VIII, 134 Stat. 281, 563 (2020). Of the $178 billion, $139 billion was allocated for relief
payments to providers and the other $39 billion was allocated for other distributions,
including treatment and testing for the uninsured and underinsured, as well as vaccine
and therapeutic development and procurement activities.
2For the purpose of this report, we focused exclusively on HRSA’s administration and
oversight of the $139 billion in allocations for relief payments to providers and not the
other $39 billion allocated for other distributions. In addition to the PRF, the American
Rescue Plan of 2021 appropriated $8.5 billion for relief to rural providers for health care
related expenses and revenue losses attributable to COVID-19; these funds are also
outside the scope of this report.
3In June 2023, the Fiscal Responsibility Act of 2023 rescinded unobligated PRF funds for
provider relief payments. Pub. L. No. 118-5, div. B, tit. I, § 2. Additionally, based on the
decline in COVID-19 deaths and hospitalizations, the Secretary of HHS ended the federal
public health emergency for COVID-19 on May 11, 2023, although some response
activities continue.
Page 1 GAO-23-106083 Provider Relief Fund
payments appropriately. 4 Through these control activities, HRSA
identified payments that need to be recovered, such as payments to non-
compliant providers, overpayments, and unused payments.
The CARES Act includes a provision for GAO to monitor and oversee the
federal government’s efforts to prepare for, respond to, and recover from
the COVID-19 pandemic. 5 In this report we
1. describe PRF payment distributions;
2. examine HRSA’s efforts to ensure that PRF payments were
distributed only to eligible providers in correct amounts;
3. examine HRSA’s efforts to ensure that PRF payments were used
according to program requirements, and assess the risks of fraud in
the PRF; and
4. examine the status of HRSA’s recovery of PRF payments to non-
compliant providers, overpayments, and unused payments.
To describe PRF payment distributions, we obtained HRSA data on PRF
payments from April 2020 through December 2022, along with data on
provider acceptance of the PRF program requirements or rejection of
PRF payments. Nearly all PRF payments had been distributed by the end
of December 2022. We also analyzed HRSA data on PRF payments by
provider type. We used HRSA’s provider type categories to further
categorize PRF recipients into seven broad provider type categories: (1)
hospital or inpatient providers, (2) non-hospital-based health systems, (3)
hospital-based health systems and hospital-affiliated providers, (4)
outpatient providers, (5) clinicians and practitioners, (6) long-term care
and skilled nursing facilities, and (7) other providers. 6 Many health care
4Medicare is a federally financed health insurance program for persons aged 65 and over,
certain individuals with disabilities, and individuals with end-stage renal disease. Medicaid
is a joint federal-state program that finances health insurance coverage for certain low-
income and medically needy individuals. The Children’s Health Insurance Program is a
joint federal-state program that finances health insurance for low-income children whose
household incomes do not qualify them for Medicaid.
5Pub. L. No. 116-136, § 19010, 134 Stat. at 579–81.
6Our analysis focused on the provider entities that received payments. These entities may
have re-distributed the payments to their subsidiary providers in accordance with program
guidance.
Page 2 GAO-23-106083 Provider Relief Fund
systems that include hospitals also include a variety of other provider
types. Providers in the “hospital-based health systems and hospital-
affiliated providers” category may include other provider types owned by
hospital systems, such as hospital-owned outpatient facilities, along with
distinct provider entities that are affiliated with hospital systems, such as
hospital-affiliated long-term care facilities. According to HRSA officials,
payments in this category may underrepresent the proportion of funding
received by other provider types since payments to distinct provider
entities that are affiliated with hospitals may be included in this category.
This may also accordingly overrepresent the proportion of payments to
hospital entities.
To examine HRSA’s efforts to ensure that PRF payments were distributed
only to eligible providers in correct amounts, we reviewed HRSA payment
integrity documentation, including the agency’s payment review manual
and program risk assessments, and we interviewed agency officials about
payment integrity oversight activities. We obtained data on pre-payment
reviews conducted as of December 2022, and post-payment reviews
completed as of May 2023, the most recent data at the time of our review.
We analyzed and compared HRSA data and documentation on the
completion of post-payment reviews to the agency’s goals for these
payment integrity reviews.
Also as part of our examination of HRSA’s efforts, we reviewed providers’
experiences verifying the accuracy of their PRF payments. HRSA
established a contractor-operated provider support line to help providers
with the PRF program; we interviewed the contractor to learn about
provider experiences verifying the accuracy of their payments. In addition,
we analyzed HRSA resources for PRF recipients, such as program
guidance materials and webinars. We also conducted interviews with 10
selected health care provider and health care management organizations
to determine providers’ experiences with PRF payments; these interviews
are not generalizable to the entire health care provider population. 7 We
Providers in the “hospital and inpatient facilities” category include hospitals, inpatient
behavioral health facilities and other inpatient facilities that are distinct from hospitals.
Providers in the “clinician and practitioners” category include physician practices and
dentists, among others. Providers in the “other providers” category include home health,
hospice, diagnostic, and transportation providers, and equipment suppliers, among others.
7We interviewed the American Dental Association, American Health Care
Association/National Center for Assisted Living, American Hospital Association, American
Medical Association, Children’s Hospital Association, Healthcare Financial Management
Association, Medical Group Management Association, National Association for Home
Care & Hospice, and National Rural Health Association.
Page 3 GAO-23-106083 Provider Relief Fund
selected organizations representing the different types of providers that
received PRF payments targeted to them. 8 We also reviewed data from
payment reconsiderations—a process for providers to dispute the amount
of payments they received—as of March 2023.
To examine HRSA’s efforts to ensure that PRF payments were used
according to the program’s requirements, we reviewed HRSA’s
documentation on provider requirements for reporting on their use of the
payments, audit processes, and efforts to address fraud. We interviewed
HRSA officials regarding these efforts. We also obtained HRSA data on
provider compliance with reporting requirements for payments distributed
from April 2020 through June 2021, and provider selection for compliance
audits for payments distributed from April 2020 through June 2020. As
part of our review of HRSA’s efforts to ensure appropriate use of
payments, we also examined HRSA’s efforts to assess fraud risks in the
program, and reviewed the extent to which HRSA implemented
recommendations in the agency’s fraud risk assessments for the PRF
program. 9
To examine the status of HRSA’s recovery of PRF payments to non-
compliant providers, overpayments, and unused payments, we obtained
and analyzed HRSA documentation, reports, and data on the agency’s
recovery activities. 10 The reports and data included payment amounts to
be recovered—such as identified overpayments and unused payments—
along with data on payment amounts recovered by HRSA as of May
8We selected organizations that represent (1) Medicare and Medicaid provider types, and
(2) provider types that received targeted PRF payments, such as skilled nursing facilities
and rural health care facilities.
9Fraud risk assessments involve reviewing agency control activities to prevent, identify,
and respond to fraud, with an emphasis on prevention, as well as structures and
environmental factors that influence or help agencies achieve their objective to mitigate
fraud risks. For more information, see GAO, A Framework for Managing Fraud Risks in
Federal Programs, GAO-15-593SP (Washington, D.C.: July 28, 2015). The Payment
Integrity Information Act of 2019 requires the Office of Management and Budget (OMB) to
provide guidance to agencies in implementing the Fraud Risk Framework, and OMB has
emphasized the importance of using the Fraud Risk Framework to implement effective
program controls. See Pub. L. No. 116-117, § 2(a), 134 Stat. 113, 131-132 (2020), and
Office of Management and Budget, Establishing Financial and Administrative Controls to
Identify and Assess Fraud Risk, CA-23-03 (Washington, D.C.: Oct. 17, 2022).
10We defined non-compliant providers as those that failed to meet program requirements
(such as the reporting requirements), had audit findings, or did not return payments as
required (such as rejected payments). For the purposes of this report, we consider
payment offsets—reduced subsequent payments to providers to recover funds from
previous payments—recoveries.
Page 4 GAO-23-106083 Provider Relief Fund
2023, the most recent data at the time of our review. We also interviewed
HRSA officials to determine the agency’s progress in implementing
payment recovery activities. We compared HRSA’s recovery activities to
the agency’s policies and guidance, and to the Office of Management and
Budget’s (OMB) requirements that agencies promptly recover payments
that should be returned. 11
To assess the reliability of all data used, we reviewed relevant agency
documentation, interviewed HRSA officials and officials with the
Pandemic Response Accountability Committee regarding the data and its
limitations, and manually and electronically examined the data for obvious
errors and consistency across datasets. 12 We determined that the data
were sufficiently reliable for the purposes of our reporting objectives.
We conducted this performance audit from June 2022 to September 2023
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.
Background
Provider Relief Fund To administer financial relief for losses and expenses related to the
Distribution Methods and COVID-19 pandemic, HRSA distributed two separate types of PRF
payments: general payments to eligible health care providers and
Time Frames
targeted payments to certain types of providers. The targeted payments
included payments to skilled nursing facilities, tribal health care providers,
and rural health care facilities. 13 HRSA distributed general payments in
11See Office of Management and Budget, Transmittal of Appendix C to OMB Circular A-
123, Requirements for Payment Integrity Improvement, OMB Memorandum M-21-19
(Washington, D.C.: Mar. 5, 2021).
12The Pandemic Response Accountability Committee aggregated federal pandemic
spending data across agencies. The CARES Act established the Pandemic Response
Accountability Committee within the Council of Inspectors General on Integrity and
Efficiency, the oversight and coordination body for the inspector general community. Pub.
L. No. 116-136, § 15010(b), 134 Stat. 281, 534 (2020). The committee is composed of 21
inspectors general.
13Providers that received general payments were also eligible to receive targeted
payments.
Page 5 GAO-23-106083 Provider Relief Fund
four phases beginning in April 2020 and ending in June 2023; eligible
health care providers included those enrolled in Medicare, Medicaid, and
the Children’s Health Insurance Program. HRSA distributed targeted PRF
payments beginning in May 2020, with many of the targeted payments
sent to providers that were acutely impacted by the COVID-19 pandemic.
For example, HRSA distributed targeted payments to high-impact
hospitals that had a high number of COVID-19 patient admissions, and to
nursing facilities, whose residents and staff were disproportionately
affected by COVID-19.
Most phase 1 general payments and targeted payments were sent
automatically to providers, while all other general payments were based
on applications submitted by providers (application-based payments). For
the automatic payments, HRSA used information available to the agency
to determine payment amounts. For example, HRSA used COVID-19
hospital admission data to determine targeted payment amounts to high-
impact hospitals. HRSA relied on reported revenues and expenses from
provider applications to determine general payment amounts for the
application-based payments. See table 1 for information on the general
and targeted payment distributions, provider eligibility, and payment
distribution methods.
We previously reported on pandemic relief to tribal entities, including PRF distributions to
tribal health care providers. See GAO, COVID-19 Relief Funds: Lessons Learned Could
Improve Future Distribution of Federal Emergency Relief to Tribal Recipients,
GAO-23-105473 (Washington, D.C.: Dec. 15, 2022).
Page 6 GAO-23-106083 Provider Relief Fund
Table 1: Provider Relief Fund General and Targeted Payment Distributions
Date of initial Payment
Description distributions Eligible providers distribution method
General distributions
Phase 1 April 10, 2020 Medicare providersa Automatic and application
based
Phase 2 July 3, 2020 Medicaid and Children’s Health Insurance Program Application based
providers, dental providers, assisted living facilities,
and Medicare providersb
Phase 3 November 16, Providers eligible under phases 1 and 2, and Application based
2020 behavioral health providersc
Phase 4 December 16, Providers eligible under phases 1, 2, and 3, and those Application based
2021 that received a prior targeted distribution
Targeted distributions
Rural health care facilities May 6, 2020 Hospitals, clinics, and federally qualified health centers Automatic
in rural areas
High-impact hospitals May 7, 2020 Hospitals that had a high number of COVID-19 Automatic
admissions
Skilled nursing facilities May 22, 2020 Skilled nursing facilities and nursing homes Automatic
Tribal health care providers May 29, 2020 Tribal hospitals, clinics, and health centers Automatic
Safety net hospitals June 12, 2020 Hospitals that provide care to vulnerable populations Automatic
and operate on thin profit margins
Children’s hospitals August 20, 2020 Children’s hospitals Automatic
Nursing home infection August 27, 2020 Skilled nursing facilities and nursing homes Automatic
control, quality, and
performance
Source: GAO analysis of Health Resources and Services Administration (HRSA) information. | GAO-23-106083
Note: Providers that received general payments were also eligible to receive targeted payments.
a
Medicare is a federally financed health insurance program for persons aged 65 and over, certain
individuals with disabilities, and individuals with end-stage renal disease.
b
Medicare providers that received payments under phase 1 could have been eligible for phase 2
payments. Medicaid is a joint federal-state program that finances health insurance coverage for
certain low-income and medically needy individuals. The Children’s Health Insurance Program is a
joint federal-state program that finances health insurance for low-income children whose household
incomes do not qualify them for Medicaid.
c
While providers that received payments under phase 1 and 2 were eligible for phase 3 payments,
any prior payments were deducted from their phase 3 payment.
Provider Relief Fund Providers that received PRF payments were subject to a number of
Requirements and program requirements, including requirements related to their use of the
payments. In particular, providers could only use PRF payments to cover
Payment Integrity
COVID-19-related losses or expenses—including losses related to
Page 7 GAO-23-106083 Provider Relief Fund
postponed patient care and expenses related to supplies, such as
personal protective equipment, and facility upgrades to limit the spread of
COVID-19. PRF payments could only be used for losses and expenses
that were not reimbursed from other sources, such as other COVID-19-
related federal financial assistance from the Paycheck Protection
Program, a Small Business Administration program for small
businesses. 14 Within 90 days of receiving a payment, providers were
required to attest to their receipt of the payments and agreement with
program requirements, or reject the payment through an attestation web
portal established by HRSA. HRSA informed providers that if they did not
attest through the portal, but kept the PRF payment for more than 90
days, they were considered to have passively attested to their acceptance
of both the payments and the requirements.
HRSA also required providers that received more than $10,000 in
aggregate in a given distribution period to report on their use of PRF
payments through a separate reporting web portal, so that the agency
can conduct audits to review whether providers used the payments
according to program requirements. HRSA implemented the reporting
requirement on a rolling basis depending on when providers received the
payments, so providers may be required to report more than once. 15 As of
March 31, 2023, the reporting deadline has passed for providers that
received and retained payments from on or before December 31, 2021—
representing nearly $130 billion in payments. See table 2 for additional
information about provider reporting deadlines.
14Providers may have received other COVID-19-related assistance from several sources,
including the Department of the Treasury, the Small Business Administration, the Federal
Emergency Management Agency, and local, state, and tribal government assistance
sources. Providers may not keep PRF payments for losses and expenses covered by
other assistance. For example, if a provider received $2 million in Paycheck Protection
Program relief and $1 million in PRF payments, and incurred $2 million in COVID-19-
related losses and expenses, the provider may not keep the PRF payments since the
entirety of the provider’s losses and expenses were covered by other assistance.
15For example, providers that received more than $10,000 in aggregate between April
2020 and June 2020 were required to report on their use of payments by November 30,
2021. If those same providers then received more than $10,000 in aggregate between
July 2020 and December 2020, they were required to again report on their use of
payments received during the period by March 31, 2022.
Page 8 GAO-23-106083 Provider Relief Fund
Table 2: Provider Relief Fund Reporting Deadlines
Distribution period Dates of payment distributions Reporting deadline
Period 1 April 10, 2020 through June 30, 2020 November 30, 2021a
Period 2 July 1, 2020 through December 31, 2020 March 31, 2022
Period 3 January 1, 2021 through June 30, 2021 September 30, 2022
Period 4 July 1, 2021 through December 31, 2021 March 31, 2023b
Period 5 January 1, 2022 through June 30, 2022 September 30, 2023
Period 6 July 1, 2022 through December 31, 2022 March 31, 2024
Period 7 January 1, 2023 through June 30, 2023 September 30, 2024
Source: Health Resources and Services Administration (HRSA). | GAO-23-106083
Note: The distribution periods—which are associated with the timing of when providers received
payments—differ from the general distribution phases in table 1—which are associated with the type
of payment. For example, a phase 1 payment to a Medicare provider could have been made in July
2020 during distribution period 2.
a
HRSA’s deadline for provider reporting was September 30, 2021, but the agency extended a grace
period to November 30, 2021.
b
HRSA subsequently offered providers an extended opportunity to report late in the case of
extenuating circumstances. Providers approved to report late were required to do so by June 2, 2023.
In addition to HRSA’s audits of providers’ use of PRF payments, certain
providers may be subject to Single Audit Act requirements based on their
PRF payments. The Single Audit Act requires non-federal and nonprofit
entities that expend more than $750,000 in federal awards in a fiscal year
to undergo single audits, unless a specific exception applies. 16 Single
audits are independent audits of an entity’s financial statements and
federal awards, or program-specific audits. HHS applies single audit
requirements to for-profit entities that receive $750,000 or more in annual
aggregated HHS awards as well. 17 Among other things, such audits can
help identify noncompliance with program requirements and help ensure
the appropriate use of payments. Providers that received PRF payments
may be subject to such audits, and HRSA is required to follow up on audit
findings to help ensure that appropriate and timely actions are taken to
address the findings.
As part of its payment integrity activities, HRSA seeks to recover PRF
payments from non-compliant providers, overpayments, or unused
payments. According to program requirements, payments issued to
1631 U.S.C. § 7502; 2 C.F.R. § 200.501.
1745 C.F.R. §§ 75.216, 75.501.
Page 9 GAO-23-106083 Provider Relief Fund
providers deemed ineligible or noncompliant (such as those that do not
report on their use of funds), unused payments, or overpayments, must
be returned as repayments to the agency. 18 The agency sends repayment
notices requesting the return of payments from providers. HRSA may
send multiple notices, but once HRSA sends a final, formal repayment
notice, the provider must submit a repayment within 60 days or request a
decision review. An appeal for decision review pauses the repayment
request until the agency conducts an independent review and makes a
determination regarding the need for repayment, which generally takes
between 60 to 120 days. If the review determines that repayment is
necessary and the provider does not submit repayment within 60 days,
then HRSA refers the provider to HHS’s Program Support Center for the
initiation of debt collection activities. 19
As of December 2022, HRSA had distributed more than $135 billion in
Hospital-Based PRF payments that were kept by providers, the majority of which were
Health Systems and distributed to hospital-based health systems and hospital-affiliated
providers. 20 In total, HRSA made more than 770,000 separate PRF
Hospital-Affiliated payments. Because HRSA distributed PRF payments to providers over
Providers Received multiple phases, providers may have received more than one payment.
The average number of PRF payments per provider was 1.8. See table 3
the Majority of for a summary of PRF payments by phase as of December 2022.
Provider Relief Fund
Payment Distributions
18In certain cases, HRSA recovered payments by offsetting later PRF payments to
providers.
19The Program Support Center, a separate organization within HHS, is responsible for the
department’s debt collection activities, which include accrual of interest, penalties, and
recovery of funds by offsetting other federal payments. These activities are executed in
partnership with the Department of the Treasury, which receives debts referred by the
Program Support Center for collections.
20HRSA distributed nearly $146 billion to providers in PRF payments and providers
returned more than $10 billion.
Page 10 GAO-23-106083 Provider Relief Fund
Table 3: Provider Relief Fund (PRF) Payments Kept by Providers, as of December 2022
Payments kept by providersa
Description (dollars in billions)
General distributions
Phase 1: Medicare providers $41.8
Phase 2: Medicaid and Children’s Health Insurance Program providers 3.1
Phase 2: dental providers 1.0
Phase 2: assisted living facilities 0.4
Phase 3: general distributionsb 18.8
Phase 4: general distributions 15.4
Subtotal of general distributions $80.5
Targeted distributions
Rural health care facilities 10.7
High-impact hospitals 20.7
Skilled nursing facilities 4.7
Tribal health care providers 0.5
Safety net hospitals 12.8
Children’s hospitals 1.1
Nursing home infection control, quality, and performance 4.5
Subtotal of targeted distributions $54.9
Total of general and targeted distributions $135.4
Source: Health Resources and Services Administration (HRSA). | GAO-23-106083
Note: Totals may not sum due to rounding.
a
HRSA distributed nearly $146 billion to providers in PRF payments and providers returned more than
$10 billion. Payments kept by providers represent total payments retained.
b
Phase 3 general distributions include payments made during HRSA’s reconsideration process, which
allowed providers to contest initial payments they believed were calculated incorrectly.
Hospital-based health systems and hospital-affiliated providers received
more than 60 percent of PRF payments, our analysis of HRSA data
show. 21 Other provider types, such as outpatient facilities, clinicians and
21Many health care systems that include hospitals also include a variety of other provider
types. Providers in the “hospital-based health systems and hospital-affiliated providers”
category may include other provider types owned by hospital systems, such as hospital-
owned outpatient facilities, along with distinct provider entities that are affiliated with
hospital systems, such as hospital-affiliated long-term care facilities. According to HRSA
officials, payments in this category may underrepresent the proportion of funding received
by other provider types since payments to distinct provider entities that are affiliated with
hospitals may be included in this category. This may also accordingly overrepresent the
proportion of payments to hospital entities.
Page 11 GAO-23-106083 Provider Relief Fund
health care practitioners, and long-term care and skilled nursing facilities,
each received less than 10 percent of the total distributed payments.
Entities that received PRF payments may have redistributed their
payments to subsidiary providers. For example, a hospital-based health
system could have redistributed PRF payments to subsidiary outpatient or
long-term care facilities. See figure 1 for detailed information about PRF
payments kept by providers by provider type.
Figure 1: Provider Relief Fund (PRF) Payments Kept by Providers, by Type of
Provider, as of December 2022
Notes: Data in this figure represent the entity that received PRF payments. These entities may have
redistributed the payments to their subsidiary providers in accordance with program guidance.
Providers in the “hospital and inpatient facilities” category include hospitals, inpatient behavioral
health facilities and other inpatient facilities that are distinct from hospitals. Providers in the “clinicians
and healthcare practitioners” category include physician practices and dentists, among others.
Providers in the “other” category include home health, hospice, diagnostic, and transportation
providers, and equipment suppliers, among others.
Many health care systems that include hospitals also include a variety of other provider types.
Providers in the “hospital-based health systems and hospital-affiliated providers” category may
include other provider types owned by hospital systems, such as hospital-owned outpatient facilities,
along with distinct provider entities that are affiliated with hospital systems, such as hospital-affiliated
long-term care facilities. According to HRSA officials, payments in this category may underrepresent
the proportion of funding received by other provider types since payments to distinct provider entities
that are affiliated with hospitals may be included in this category. This may also accordingly over-
represent the proportion of payments to hospital entities.
The majority of PRF payments were associated with providers that
actively attested to the program’s requirements, as opposed to passively
Page 12 GAO-23-106083 Provider Relief Fund
accepting the payments. Of the providers that either actively or passively
attested to PRF program requirements, providers kept more than 90
percent of the payment amounts. (See fig. 2.)
Figure 2: Provider Relief Fund (PRF) Payments Kept and Returned by Providers, by
Active and Passive Attestation to Program Requirements, and Rejected Payments,
as of December 2022
Note: Providers that received PRF payments were required to attest to their acceptance or rejection
of the program’s requirements. Providers that retained their payments for more than 90 days were
considered to have passively attested to their acceptance of the requirements.
Payment totals shown in figure 2 represent all distributed funds—both payments kept and returned by
providers—which vary from totals in table 3 and figure 1, which include only payments kept by
providers. Further, the kept amounts may vary from totals in table 3 and figure 1 as a result of timing
differences in HRSA updates to the datasets used for the analyses.
HRSA distributed the majority of PRF funds to recipients via automatic
payments. As of December 2022, automatic payments accounted for
nearly 67 percent of the total payments. Application-based payments
accounted for 33 percent of payments. (See fig. 3.)
Page 13 GAO-23-106083 Provider Relief Fund
Figure 3: Application and Automatic Provider Relief Fund (PRF) Payments, as of
December 2022
Note: HRSA sent PRF payments to recipients automatically or as the result of applications submitted
by the provider. For automatic payments, HRSA used information available to the agency to
determine payment amounts. For application-based payments, HRSA relied on information from
provider applications to determine payment amounts.
Payment totals shown in figure 3 represent all distributed funds—both payments kept and returned by
providers—which vary from totals in table 3 and figure 1, which include only payments kept by
providers.
HRSA Reviewed
Payments to Ensure
Eligibility and
Accuracy, but Has
Delayed Completion
of Reviews
HRSA Reviewed Provider To help ensure payment accuracy, HRSA conducted pre-payment
Eligibility and Financial reviews to verify provider eligibility and pre-payment reviews of the
financial information on PRF applications to verify payment amounts.
Information Prior to
HRSA checked for ineligible providers prior to payment, such as those
Payment excluded from participating in federal health care programs, including
Medicare and Medicaid. HRSA also verified the accuracy of provider-
reported revenue losses against documentation submitted by providers,
such as their tax returns, to ensure correct payment amounts.
Page 14 GAO-23-106083 Provider Relief Fund
According to agency officials, HRSA used factors based on the level of
risk to select provider applications for pre-payment review. For example,
applications with PRF payments amounts over a certain threshold,
applications that appeared to be potentially duplicative, or applications
with a suspicious email address (such as @dr.com) were selected for
review. Our analysis of PRF data found that as of December 2022, HRSA
had conducted these pre-payment reviews of financial information for
about 54 percent (about $26.7 billion of $49.0 billion) of the application
based payments issued.
Ongoing HRSA Delays in In addition to pre-payment reviews, HRSA also conducted post-payment
Reviewing Payments reviews of distributed payments, though the agency has experienced
ongoing delays in completing the reviews. 22 In December 2020, agency
Have Impeded the
documentation showed that HRSA began to identify potential payment
Identification of Potential errors—referred to as payment discrepancies—and began conducting
Overpayments post-payment reviews of these discrepancies. According to HRSA, the
post-payment reviews are data-driven analyses designed to identify PRF
overpayments and payments that should not have been made and need
to be recovered. For example, one discrepancy type was payments made
based on potentially duplicate provider applications, which resulted in the
identification of overpayments of funds to be recovered from providers.
As of May 2023, HRSA documentation showed that of the 59 post-
payment reviews the agency conducted, 38 were closed and 21 remained
open. HRSA closed a number of reviews based on its determination that
other planned and ongoing program integrity processes would address
the underlying payment integrity issues associated with the payment
discrepancies. For example, HRSA closed 10 reviews because required
provider reporting and audits would address the issues. HRSA closed
another four reviews based on the planned implementation of a separate
payment integrity process for addressing irregular and problematic
payments. For example, in July 2022, HRSA closed post-payment
reviews for PRF applications that used personal rather than business
email addresses or personal bank accounts on the basis that the payment
irregularities process would review and address the issues. However, the
payment irregularities process was not implemented until March 2023.
(See table 4.)
22Throughout this report, the term “post-payment reviews” refers to HRSA’s post-payment
quality control reviews.
Page 15 GAO-23-106083 Provider Relief Fund
Table 4: Status of Provider Relief Fund (PRF) Post-Payment Reviews, as of May 2023
Number of
Status of post-payment reviews and reasons for closure post-payment reviews
Open 21
Open; overpayments identified for repayment, and funds recovereda 1
Open; overpayments identified for repayment, but not yet recovereda 8
Open; no payments identified for repayment yet 12
Closed 38
Closed; overpayments identified and recoveredb 1
Closed; consolidated with other, similar reviews 5
Closed; payment irregularities found and addressed through policy changes, other controls, or 4
case management
Closed, issue with the Department of Health and Human Services Office of Inspector General 2
Closed, other resolution identified 9
Closed; any potential discrepancy will instead be addressed through provider reporting and 10
audits
Closed; any potential discrepancy will instead be addressed through a new payment 4
irregularities workflow process
Closed; documentation and final memo not yet availablec 3
Total post-payment reviews 59
Source: GAO analysis of Health Resources and Services Administration (HRSA) data. | GAO-23-106083
a
As of May 2023, HRSA had identified about $242 million in overpayments to be recovered based on
nine open reviews. Of that amount, about $77 million had been recovered through offsets, about
$10,000 had been recovered through provider repayment, and the remainder had not yet been
recovered.
b
As of May 2023, based on this closed post-payment review, HRSA had identified $60 million in
overpayments and recovered the funds through $15 million in repayments from providers and $45
million in offsets of subsequent payments. In addition, HRSA identified and recovered $11 million
through an individual case not associated with a specific post-payment review.
c
According to HRSA procedures, the agency is to document reasons for closing post-payment
reviews in a final memo. As of the dates specified, HRSA documentation and final memos were not
yet available.
As of May 2023, about one-third—21 of 59—of post-payment reviews
remained open, despite most PRF payments being issued in 2020 and
2021. Agency documents from January 2022 had scheduled all but one
ongoing review to be completed by the end of 2022. Further, the 21 open
reviews represent no change since September 2022, when the totals
were the same. Of the 21 reviews that remained open in May 2023,
HRSA officials told us they had partially completed some of the open
reviews, but were leaving them open until all related PRF payments were
Page 16 GAO-23-106083 Provider Relief Fund
issued. Thus far, nine of the open reviews have identified overpayments
for potential recovery.
Due to concerns about delays, in October 2021, we recommended that
HRSA expeditiously complete the remaining post-payment reviews to
identify potential overpayments. HRSA partially agreed with our
recommendation, but has not implemented it as of April 2023. 23 HRSA
officials also told us that the agency has experienced delays in closing the
post-payment reviews because the reviews have required extensive
discussions and collaborations with other HHS agencies. HRSA officials
told us they recently established a team to complete the reviews, and
they plan to complete the reviews by the end of calendar year 2023. We
reiterate the importance of taking prompt action to complete post-
payment reviews and identify potential overpayments.
HRSA has Taken Steps to To help ensure the accuracy of PRF payments, HRSA asked providers to
Better Ensure Payment report payment errors to the agency. However, HRSA communications to
providers did not include provider-specific information on their payment
Accuracy by Addressing
amounts. Several of the selected provider organizations we spoke with
Provider Challenges noted that providers experienced challenges verifying the accuracy of
Verifying Their Payment their PRF payments. HRSA has since taken steps to address such
Amounts concerns and better ensure payment accuracy by improving its provider
support line and establishing a process for providers to request
reconsideration of payments they believed were incorrectly calculated.
HRSA officials told us they did not communicate individual payment
calculations or payment amounts to providers, because it would have
been time-intensive and cost-prohibitive to do so. Instead, HRSA posted
payment calculation methodologies on the agency’s PRF website.
However, according to seven provider organizations we spoke with,
providers found HRSA’s payment methodologies complex and difficult to
use. In addition, a provider organization and a health care management
organization we spoke with told us that some providers with subsidiaries
(such as health care systems with separate outpatient clinics) did not
know if the payments they received included payments for their
subsidiaries. In other cases, HRSA capped amounts used for payment
calculations for providers with higher-than-expected revenues or losses
23See GAO, COVID-19: Additional Actions Needed to Improve Accountability and
Program Effectiveness of Federal Response, GAO-22-105051 (Washington, D.C.: Oct.
27, 2021).
Page 17 GAO-23-106083 Provider Relief Fund
relative to their peer providers, but did not directly communicate this
information to the affected providers. 24
HRSA helped address these provider challenges by improving the
program’s provider support line. In April 2020, HRSA established a
contractor-operated provider support line, in part, to address provider
questions about payments. However, contractor staff could only answer
inquiries using information from publicly available PRF guidance, which
according to three provider organizations we spoke with, limited its
usefulness in addressing providers’ payment-specific questions.
Contractor officials told us that they were able to address most provider
inquires, although they acknowledged that some providers were
frustrated by the lack of provider-specific information. Subsequently, in
February 2021, HRSA established an additional provider support line with
HRSA staff who had access to provider-specific information. Two of the
provider organizations we spoke with said that providers found HRSA
staff helpful in answering questions about specific payment amounts.
In addition, in 2021, HRSA established a process where providers could
request reconsideration of PRF payments they believed were incorrectly
calculated. As of March 2023, HRSA had reviewed more than 3,600
reconsideration requests and redistributed an additional $1.67 billion to
325 providers for phase 3 payments based on those requests. HRSA had
planned to include a reconsideration process for phase 4 payments, but
no reconsideration payments were made prior to the rescission of
remaining PRF funds for provider relief in June 2023. 25
24For phase 3 payment distributions, HRSA used loss ratios (which they defined as
reported losses divided by annual patient care revenue) to calculate payments and
capped the loss ratios for some providers, which resulted in reduced payments to those
providers. HRSA used the loss ratio as a measure to ensure that similar providers’
reported revenues and losses were within a set range. According to the PRF payment
methodology, capped loss ratios served as a risk mitigation and cost-containment
safeguard. While HRSA did not inform providers when the capped loss ratios were applied
to their payments, the methodology for phase 3 payments posted on HRSA’s PRF website
informed providers of the possible adjustment.
25In June 2023, the Fiscal Responsibility Act of 2023 rescinded unobligated PRF funds for
provider relief payments. Pub. L. No. 118-5, div. B, tit. I, § 2.
Page 18 GAO-23-106083 Provider Relief Fund
HRSA Has Initiated
Audits of Providers’
Reported Use of
Relief Payments and
Implemented Its
Recommendations to
Address Potential
Fraud
HRSA has Initiated Audits According to HRSA documentation and officials, the agency has been
of Provider’s Reported conducting audits on a sample of providers to verify that providers used
their PRF payments according to program requirements. Providers that
Use of Provider Relief
received more than $10,000 in PRF payments in aggregate in a given
Fund Payments distribution period were subject to HRSA’s requirement to report on their
use of the funds and generally complied with the requirement. Nearly all
PRF payments distributed were subject to the reporting requirement.
Based on our analysis of HRSA data, about half of providers received
more than $10,000 in PRF payments, and these providers received more
than 99 percent of the PRF payments distributed. Of the providers
required to report on their use of payments received from April 2020
through June 2021, more than 92 percent reported. 26
According to agency documentation, as part of the audits, HRSA plans to
verify the accuracy of providers’ reported information on how they used
the payments. For example, the audit procedures include reviews of
providers’ invoices and receipts for COVID-19-related expenses to verify
providers’ reported expenses. Additionally, HRSA plans to identify and
determine the amount of other COVID-19-related assistance received by
providers, such as other federal financial assistance, to ensure that PRF
payments were only used for COVID-19-related losses and expenses not
otherwise reimbursed from other sources.
26Because providers report on their use of PRF payments on a rolling basis, these data
may count individual providers who reported on payments more than once. For example,
a provider that received more than $10,000 from one PRF distribution, and then later
received more than $10,000 from another distribution, may have been required to
separately report on their use of the two distributions.
Page 19 GAO-23-106083 Provider Relief Fund
Starting in January 2022, HRSA initiated pilot audits on four provider
organizations, and according to agency officials, these audits were
scheduled to be completed by February 2023. As of June 2023, HRSA
had completed the audits and plans to finalize the audits by issuing
reports to the four organizations, according to HRSA officials. 27 In August
2022, HRSA began auditing 30 additional provider organizations. 28 These
34 provider organizations received more than $3 billion in PRF payments
from April 2020 through June 2020, or about 4 percent of payments that
were subject to reporting requirements during the time period. As of May
2023, HRSA anticipates completing the first round of audits in August
2023. According to agency officials, HRSA has selected providers who
received PRF payments from July 2020 through December 2020 for audit
and plans to initiate those audits later in 2023.
HRSA selected providers for audit by developing a risk score for each
provider based on payment amounts and other factors. For example,
providers that received larger payments received higher risk scores.
Further, as part of its obligation to review all single audit findings, as of
June 2023, HRSA identified 321 providers that did not use PRF payments
in accordance with program requirements, according to fiscal year 2021
and 2022 single audits.
In addition to using provider reporting to conduct audits, HRSA used
provider reporting to identify PRF payments that went unused by
providers. HRSA compared providers’ payment amounts against their
reported losses and expenses to determine if any portion of their
payments went unused. According to the PRF’s terms and conditions,
unused payments should be returned to HRSA.
27HRSA’s audits of these four provider organizations include 38 subsidiary providers, for a
total of 42 providers.
28HRSA’s audits of these 30 provider organizations include 180 subsidiary providers, for a
total of 210 providers.
Page 20 GAO-23-106083 Provider Relief Fund
HRSA Conducted Fraud As part of HRSA’s efforts to ensure providers used PRF payments
Risk Assessments and appropriately, the agency conducted fraud risk assessments to assess
and implement controls to help reduce the risk for fraud in the program. In
Recently Implemented Its
2021 and 2022, HRSA conducted fraud risk assessments to identify
Recommendations for
Identifying and • fraud risks to the PRF program,
Coordinating Its Response • existing controls in place to mitigate those risks,
to Potential Fraud • the remaining risks that could leave the program vulnerable to fraud,
and
• recommendations to address them.
HRSA identified a number of existing controls in place to address
identified fraud risks. For example, according to the assessments,
HRSA’s pre-payment reviews of provider documentation limited providers’
ability to submit false financial information to inflate their PRF payment
calculations. Additionally, the assessments found that HRSA took steps to
check provider information to prevent providers from submitting more
than one PRF application, limiting the potential for duplicate payments.
As part of the assessments, HRSA made recommendations in its 2021
fraud risk assessment to document procedures for certain anti-fraud
efforts to ensure consistency and coordination of activities. In its 2021
assessment, HRSA found that it had not documented analytic procedures
for what types of irregular or problematic payments should be flagged for
further review, and for responding to allegations of potential fraud; HRSA
recommended that such procedures be documented and standardized. In
March 2023 and June 2023, HRSA addressed these recommendations
by implementing and documenting the agency’s new standardized
processes for identifying and addressing irregular and problematic
payments, and for responding to allegations of potential fraud. These
processes were implemented nearly a year and a half after the 2021
fraud risk assessment and 3 years after initial payments. While
implementing these recommendations sooner would have been helpful,
formally documenting and standardizing such procedures will better
enable HRSA to consistently respond to potential fraud as the agency
moves forward with its payment integrity efforts.
Page 21 GAO-23-106083 Provider Relief Fund
Over $1 Billion in
Provider Relief Fund
Payments Remain
Unrecovered
HRSA Has Recovered As of May 2023, HRSA had recovered nearly half of the $2.6 billion in
about Half of the $2.6 payments to non-compliant providers, overpayments, and unused
payments identified for recovery. As of August 2023, the agency had
Billion Identified for
established time frames to recover the nearly $1.4 billion in payments not
Recovery yet recovered.
In December 2020, HRSA began formal recovery activities to seek
repayments from providers. Agency officials told us they later paused
sending final repayment notices to providers for 9 months, between
March and December 2022, to develop a decision review process to
adjudicate provider disputes of HRSA’s decisions to seek repayment of
funds, and to finalize the process for the Program Support Center to
serve as HRSA’s collection agent. 29 HRSA officials told us that they
implemented the decision review process in December 2022, at which
time the agency resumed formal recovery efforts by issuing final
repayment notices to non-compliant providers.
See figure 4 for the status of HRSA’s efforts to recover PRF payments as
of May 2023. HRSA may identify additional PRF payments for recovery in
the future, because its payment integrity processes—such as post-
payment reviews, provider reporting, and HRSA’s provider audits—are
ongoing.
29In December 2020, HRSA had begun to seek repayment of overpayments identified
through its post-payment reviews. HRSA recovered about $145 million from post-payment
reviews before pausing efforts in March 2022.
Page 22 GAO-23-106083 Provider Relief Fund
Figure 4: Status of the Health Resources and Services Administration (HRSA) Actions to Recover Provider Relief Fund (PRF)
Payments, as of May 2023
a
Percent does not sum to 100 due to rounding.
b
According to HRSA officials, payments recovered through offset were recovered by reducing the
amount of subsequent payments to providers.
c
Based on reporting by providers that received and kept payments from on or before June 30, 2021.
d
The Single Audit Act requires non-federal and non-profit entities that expend more than $750,000 in
federal awards in a fiscal year to undergo single audits, unless a specific exception applies. Single
audits are independent audits of an entity’s financial statements and federal awards, or program-
specific audits.
e
As of May 2023, HRSA had not completed any provider audits.
In December 2020, HRSA had begun to seek repayment of overpayments identified through its post-
f
payment reviews. HRSA had recovered about $145 million before pausing efforts in March 2022.
According to HRSA, the agency also set a threshold for recovery from providers of $25 for
overpayments, and the figure may include payments under the threshold.
As of May 2023, HRSA had either sent final repayment notices for much
of the nearly $1.4 billion in payments that have yet to be returned or
established time frames for when the final notices would be sent out. In
particular, of the $968 million in unreturned payments from non-reporting
providers, HRSA sent final repayment notices seeking about $522 million
in recoveries to about 60 percent (about 12,300 of about 20,200) of the
providers who received payments on or before June 30, 2021 (or those in
Page 23 GAO-23-106083 Provider Relief Fund
distribution periods one through three). The agency established time
frames to send the remaining final repayment notices to non-compliant
providers by September 2023. In addition, officials told us they had
referred more than 2,500 unrecovered payments to the Program Support
Center for debt collection.
As of May 2023, HRSA had not established time frames for pursuing
recovery of overpayments, unused payments, and payments from
providers that received payments from July 1, 2021, through December
31, 2021 (distribution period four), but did not comply with reporting
requirements. 30 These funds totaled nearly $250 million as of May 2023.
However, in August 2023, HRSA established time frames to send final
repayment notices by April 2024 to recover these payments.
According to HRSA policy, the agency should seek repayment from
overpayments, unused payments, and non-compliant providers. 31 OMB
policy further states that agencies should act promptly and seek to
recover payments as quickly as possible, and previous reports show that
the more time passes, the less likely it is that payments will be
recovered. 32 Accordingly, the establishment of time frames for recovering
these payments will help better ensure that HRSA succeeds in recovering
all of these funds.
30Providers that received payments from July 1, 2021 through December 31, 2021 were
required to report on their use of payments by March 31, 2023, which was the last
reporting deadline as of the time of this report. (Although HRSA subsequently offered
providers an extended opportunity to report late in the case of extenuating circumstances.)
Providers that received payments in distribution period five are required to report by
September 30, 2023; providers that received payments in subsequent distribution periods
are scheduled to complete reporting by September 30, 2024.
31In October 2021, we recommended that HRSA implement recovery of PRF
overpayments, unused payments, or payments not properly used because we found that
little action to recover payments had been taken as of August 2021. Based on our review
of HRSA’s procedures for recovery, the amount it has recovered thus far, and its planned
schedule to seek recovery of all types of payments in need of recovery, we consider
HRSA to have addressed the recommendation. We are in the process of closing the
recommendation as implemented. See GAO-22-105051.
32See Office of Management and Budget, Transmittal of Appendix C to OMB Circular A-
123, Requirements for Payment Integrity Improvement; Department of Health and Human
Services, Office of Inspector General, Medicare’s Currently not Collectible Overpayments,
OEI-03-11-00670 (Washington, D.C.: June 2013); and GAO, Debt Collection: Treasury
Faces Challenges in Implementing Its Cross-Servicing Initiative, GAO/AIMD-00-234
(Washington, D.C.: Aug. 4, 2000).
Page 24 GAO-23-106083 Provider Relief Fund
HRSA has Received HRSA has received 99.8 percent of the approximately $5.1 billion in
Nearly All Rejected PRF rejected PRF payments, as of December 2022, based on our analysis.
HRSA officials told us that most providers returned their payments upon
Payments, and Has Begun
rejecting them, and that the agency did not have to actively or formally
Recovery of Remaining seek recovery of most of these funds. Consistent with this, we found that
Rejected Payments providers returned most rejected payments during the early months of the
PRF and prior to HRSA beginning formal recovery activities in December
2020. At that time, providers had returned 92 percent (about $4.7 billion
of $5.1 billion) of rejected payments. 33
Not all providers that rejected payments returned them, and HRSA began
formal recovery efforts for rejected payments in May 2023. 34 As of
December 2022, providers that rejected PRF payments had not yet
returned about $11 million of the $5.1 billion in rejected payments. In May
2023, HRSA issued 837 final repayment notices to providers that rejected
the $11 million in payments.
We provided a draft of this report to the HHS for comment. HHS’s
Agency Comments comments are reprinted in appendix I. Our draft report included a
recommendation that HRSA establish time frames for promptly sending
final repayment notices to recover the remaining overpayments, unused
payments from providers, all non-compliant providers, and any additional
payments identified for recovery. During the agency’s review of our draft,
HRSA concurred with our recommendation and established time frames
for recovery of such PRF payments. We reviewed documentation that
HRSA provided to us, agreed that HRSA’s actions addressed our draft
recommendation, and therefore removed the recommendation from the
final report. Implementing these time frames for promptly sending final
repayment notices will help ensure that HRSA recovers PRF payments
identified for recovery.
33HRSA officials said that providers may have rejected PRF payments because they may
not have had financial need for the payments or may not have wanted to be responsible
for meeting the program requirements. Several provider and health care management
organizations we spoke with also told us that providers may have had concerns about the
program requirements, and they may have rejected payments for this reason.
34The HHS Office of the Inspector General previously reported that providers had not
returned about $50 million in rejected payments as of March 2022, and recommended that
HRSA recover these payments. See Department of Health and Human Services, Office of
the Inspector General, HHS’s and HRSA’s Controls Related to Selected Provider Relief
Fund Program Requirements Could Be Improved, A-09-21-06001 (Washington, D.C.:
September 2022).
Page 25 GAO-23-106083 Provider Relief Fund
HRSA also provided technical comments on our report, which we
incorporated as appropriate.
We are sending copies of this report to the appropriate congressional
committees and the Secretary of HHS. In addition, the report is available
at no charge on the GAO website at https://www.gao.gov. If you or your
staffs have any questions about this report, please contact me at (202)
512-7114 or GordonLV@gao.gov. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last page
of this report.
Leslie V. Gordon
Director, Health Care
Page 26 GAO-23-106083 Provider Relief Fund
List of Committees
The Honorable Patty Murray
Chair
The Honorable Susan Collins
Vice Chair
Committee on Appropriations
United States Senate
The Honorable Ron Wyden
Chairman
The Honorable Mike Crapo
Ranking Member
Committee on Finance
United States Senate
The Honorable Bernard Sanders
Chair
The Honorable Bill Cassidy
Ranking Member
Committee on Health, Education, Labor, and Pensions
United States Senate
The Honorable Gary C. Peters
Chairman
The Honorable Rand Paul, M.D.
Ranking Member
Committee on Homeland Security and Governmental Affairs
United States Senate
The Honorable Kay Granger
Chair
The Honorable Rosa L. DeLauro
Ranking Member
Committee on Appropriations
House of Representatives
The Honorable Cathy McMorris Rodgers
Chair
The Honorable Frank Pallone, Jr.
Ranking Member
Committee on Energy and Commerce
House of Representatives
Page 27 GAO-23-106083 Provider Relief Fund
The Honorable Mark E. Green, M.D.
Chairman
The Honorable Bennie G. Thompson
Ranking Member
Committee on Homeland Security
House of Representatives
The Honorable James Comer
Chairman
The Honorable Jamie Raskin
Ranking Member
Committee on Oversight and Accountability
House of Representatives
The Honorable Jason Smith
Chairman
The Honorable Richard Neal
Ranking Member
Committee on Ways and Means
House of Representatives
Page 28 GAO-23-106083 Provider Relief Fund
Appendix I: Comments from the Department
Appendix I: Comments from the Department of
Health and Human Services
of Health and Human Services
Page 29 GAO-23-106083 Provider Relief Fund
Appendix I: Comments from the Department of
Health and Human Services
Page 30 GAO-23-106083 Provider Relief Fund
Appendix II: GAO Contact and Staff
Appendix II: GAO Contact and Staff
Acknowledgments
Acknowledgments
Leslie V. Gordon, (202) 512-7114 or GordonLV@gao.gov.
GAO Contact
In addition to the contact named above Lori Achman (Assistant Director),
Acknowledgments Michael Erhardt (Analyst-in-Charge), Erin Barry, and Sylvia Diaz Jones
made key contributions to this report. Also contributing were Sandra
George, Cynthia Khan, Drew Long, Diona Martyn, Ethiene Salgado-
Rodriguez, and Emily Wilson Schwark.
Page 31 GAO-23-106083 Provider Relief Fund
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