Selected Home Health Agencies Complied With Terms and Conditions and Federal Requirements for Provider Relief Fund Payments (A-01-22-00503)
Summary
The HHS Office of Inspector General's November 2024 audit, report A-01-22-00503, found that 25 selected home health agencies complied with terms and conditions and Federal requirements for expending Provider Relief Fund payments. The PRF, a $178 billion program, provided funds to eligible providers for health care-related expenses or lost revenue attributable to COVID-19; HRSA administers it. The selected agencies reported using $108.7 million of their PRF payments to offset lost revenues, $58.8 million for general and administrative expenses and $42.1 million for health care-related expenses. The audit is part of a series reviewing PRF payments to various provider types. Because the agencies complied, the report contains no recommendations.
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November 2024 | A-01-22-00503
Selected Home Health Agencies
Complied With Terms and
Conditions and Federal
Requirements for Provider Relief
Fund Payments
OIG.HHS.GOV
November 2024 | A-01-22-00503
Selected Home Health Agencies Complied With Terms and Conditions
and Federal Requirements for Provider Relief Fund Payments
Why OIG Did This Audit
• The Provider Relief Fund (PRF), a $178 billion program, provided funds to eligible providers for health
care-related expenses or lost revenue attributable to COVID-19. HHS was responsible for initial PRF
program oversight and policy decisions, and HRSA administers 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 25 selected home health agencies (HHA) expended taxpayer funds in accordance
with Federal and program requirements.
What OIG Found
• The selected HHAs complied with terms and conditions and Federal requirements for expending PRF
funds.
• The selected HHAs reported that they used $108.7 million of their PRF payments to offset lost
revenues, $58.8 million for general and administrative expenses, and $42.1 million for health
care-related expenses.
What OIG Recommends
The selected HHAs complied with terms and conditions and Federal requirements for expending PRF funds.
Accordingly, this report does not contain recommendations.
OIG.HHS.GOV
TABLE OF CONTENTS
INTRODUCTION ............................................................................................................................... 1
Why We Did This Audit ....................................................................................................... 1
Objective ............................................................................................................................. 2
Background ......................................................................................................................... 2
COVID-19 National Emergency and the Provider Relief Fund ................................ 2
HHS’s and HRSA’s Oversight of the Provider Relief Fund Program ........................ 3
Requirements for Home Health Agencies That Received Provider Relief
Fund Payments ..................................................................................................... 5
How We Conducted This Audit ........................................................................................... 6
FINDINGS ......................................................................................................................................... 7
CONCLUSION ................................................................................................................................... 8
APPENDICES
A: Audit Scope and Methodology ....................................................................................... 9
B: Related Reports Office of Inspector General Reports .................................................. 12
C: Provider Relief Fund General and Targeted Distribution Payments ............................ 13
D: Options for Calculating Lost Revenues......................................................................... 15
E: Selected Home Health Agencies’ Reported Use of CY 2020 Provider Relief Fund
Payments ...................................................................................................................... 16
Home Health Agencies’ Compliance With Provider Relief Fund Requirements (A-01-22-00503)
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, to establish the
Provider Relief Fund (PRF). The PRF provided funds to eligible hospitals and other health care
providers (collectively “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 vaccines.1 These Federal laws
appropriated to the PRF a combined $178 billion in funds, which were generally distributed as
direct payments to providers in a series of General and Targeted Distributions. 2 As of February
2024, the Health Resources and Services Administration (HRSA) had distributed $145.9 billion of
the PRF to providers. 3
The Department of Health and Human Services (HHS) Office of the Secretary was responsible
for initial PRF program oversight and policy decisions, and HRSA, within HHS, administers the
PRF program.
COVID-19 created extraordinary challenges for the delivery of health care and human services
to the American people. As the oversight agency for HHS, the Office of Inspector General (OIG)
has provided oversight of HHS’s COVID-19 response and recovery efforts. 4 This audit assessed
selected home health agencies (HHA) compliance with terms and conditions, and Federal
requirements for expending PRF payments. It is one of several 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
1
The Coronavirus Aid, Relief, and Economic Security Act, P.L. No. 116-136, signed into law on Mar. 27, 2020,
appropriated $100 billion; the Paycheck Protection Program and Health Care Enhancement Act, P.L. No. 116-139,
signed into law on Apr. 24, 2020, appropriated $75 billion; and the Consolidated Appropriations Act, 2021,
P.L. No. 116-260, signed into law on Dec. 27, 2020, appropriated $3 billion.
2
Under the General Distributions, PRF payments were distributed in four phases (Phases 1, 2, 3, and 4). 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 and vulnerable populations, including nursing homes 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 some unobligated PRF funds. In response,
HRSA stopped making PRF payments to providers.
4
OIG, HHS-OIG's Oversight of COVID-19 Response and Recovery. As part of this plan, OIG has been conducting a
series of audits of PRF payments to hospitals, home health agencies, hospices, skilled nursing facilities, rural and/or
Tribal providers, dental providers, and assisted living facilities. This report is one in a series of these audits.
Home Health Agencies’ Compliance With Provider Relief Fund Requirements (A-01-22-00503) 1
determinations, and (3) claims for COVID-19 testing and treatment services for uninsured
individuals. See Appendix B for a list of related OIG reports.
OBJECTIVE
Our objective was to determine whether selected HHAs that received PRF payments complied
with terms and conditions and Federal requirements for expending PRF funds.
BACKGROUND
COVID-19 National Emergency and the Provider Relief Fund
On January 30, 2020, the World Health Organization declared the COVID-19 outbreak a public
health emergency of international concern, and on March 11, 2020, it characterized COVID-19
as a pandemic. 5 Then, on March 13, 2020, the President declared the COVID-19 outbreak a
national emergency. 6
As a result of the COVID-19 pandemic, 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. HHAs
subsequently experienced fewer referrals for home care services and decreased revenues that
threatened their financial viability. In addition, HHAs experienced longstanding staffing
challenges as well as new ones resulting from the pandemic, such as maintaining adequate
staffing levels. HHAs also faced numerous and widespread infection control challenges,
including accessing personal protective equipment to limit exposure and spread.7
In response to the national emergency, the PRF was established to provide funds to eligible
providers for: (1) health care-related expenses or lost revenues attributable to COVID-19, (2)
COVID-19 testing and treatment for uninsured individuals, and (3) the administration of
vaccines to the uninsured and underinsured. 8 The PRF program received a combined
5
A pandemic is an epidemic that has spread over several countries or continents, usually affecting many people.
An epidemic is an increase, often sudden, in the number of cases of a disease above what is normally expected in a
population in a specific area.
6
The national emergency ended on May 11, 2023.
7
OIG Survey Results, Home Health Agencies Used Multiple Strategies to Respond to the COVID-19 Pandemic,
Although Some Challenges Persist (OEI-01-21-00110). Issued on Oct. 18, 2022
8
HHS, Instructions for the Distribution for Medicaid, CHIP, and Dental Providers Via Enhanced Provider Relief Fund
Payment Portal. Accessed on Oct. 29, 2024. These instructions state that lost revenue attributable to COVID-19
means “the amount of any patient care revenue that you as a health care provider lost due to coronavirus, net of
any increased revenues due to coronavirus (e.g., insurance reimbursed treatment).” This revenue may include
revenue losses associated with fewer outpatient visits or canceled elective procedures or services.
Home Health Agencies’ Compliance With Provider Relief Fund Requirements (A-01-22-00503) 2
$178 billion in funding from the Coronavirus Aid, Relief, and Economic Security Act; the
Paycheck Protection Program and Health Care Enhancement Act; and the Consolidated
Appropriations Act, 2021, of which $145.9 billion was distributed to providers for health care-
related expenses or lost revenues attributable to COVID-19. 9 PRF funds were generally
distributed as direct payments to providers in a series of General and Targeted Distributions.
Exhibit 1 (on the next page) details the PRF distributions to health care providers. For further
details on how PRF payments were distributed, see Appendix C.
HHS’s and HRSA’s Oversight of the Provider Relief Fund Program
The HHS Office of the Secretary’s direct responsibility for PRF program oversight and policy
decisions allowed HHS to meet its mission to expedite the establishment of the PRF and the
distribution of funds as quickly as possible for providers’ health care-related expenses or lost
revenues attributable to COVID-19. Within HHS, HRSA is responsible for providing day-to-day
oversight and management of all aspects of the PRF program.10
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 revenues calculations.11 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.
9
Congress also appropriated $8.5 billion of COVID-19-related relief for rural providers that are enrolled in the
Medicare or Medicaid programs (American Rescue Plan Act of 2021, P.L. No. 117-2). This funding is administered
by HRSA and has similar limitations and requirements as the PRF but is not part of the PRF.
10
HHS and HRSA, PRF General & Targeted Distribution Cycle Memo, dated Sept. 30, 2020, and Sept. 30, 2021.
11
HRSA, Provider Relief: Frequently Asked Questions. Accessed on Oct. 29, 2024.
Home Health Agencies’ Compliance With Provider Relief Fund Requirements (A-01-22-00503) 3
Exhibit 1: Provider Relief Fund Distributions to Health Care Providers
Note: Amounts for the Targeted Distributions in the exhibit above do not add to $57.5 billion due to rounding.
Home Health Agencies’ Compliance With Provider Relief Fund Requirements (A-01-22-00503) 4
Requirements for Home Health Agencies That Received Provider Relief Fund Payments
Providers, including HHAs, may have been eligible to receive PRF payments from multiple
distributions.12, 13 HHAs 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, HHAs had to comply with 45 CFR § 75.302 (Financial
management and standards for financial management systems) and 45 CFR §§ 75.361 through
75.365 (Record retention and access).
As a condition of receiving PRF payments, providers agreed to the PRF terms and conditions,
including meeting eligibility criteria; filing expenditure reports; and ensuring that payments
were: (1) used to prevent, prepare for, or respond to COVID-19; (2) used for health care-related
expenses or lost revenues (i.e., patient care revenues) attributable to COVID-19; 14 (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). 15
Provider Relief Fund Expenditures and Lost Revenues
HHAs were required to use PRF distributions for expenses or lost revenues attributable to
COVID-19. For expenses, HHAs were required to report their use of PRF payments for COVID-19
health care-related expenses (e.g., expenses for purchasing equipment such as ventilators and
sanitizing supplies for infection control) and COVID-19-related general and administrative
expenses (e.g., salaries, utilities, rent), including expenses incurred prior to receipt of PRF
12
PRF payments were distributed to providers based on providers’ taxpayer identification numbers (TINs). HHAs
and other providers were required to report on their PRF payments if they received $10,000 or more during a
specified timeframe (i.e., payment period). For providers to meet this requirement, HRSA established reporting
periods, which specify when providers must 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. We use the
term “HHA” to refer to an HHA reporting entity. A HHA reporting entity may have registered its TIN through the
PRF Reporting Portal to report to HRSA on the use of PRF payments received by that TIN and TINs associated with
the entity’s subsidiary entities (e.g., individual HHAs). An HHA may be a stand-alone HHA, an HHA group, or a
parent organization.
13
For details on General and Targeted Distribution payments, see Appendix C. In addition to PRF payments, we
note that HHAs may have received other COVID-19-related assistance from the Federal Emergency Management
Agency, the Department of the Treasury, and the Small Business Administration, as well as from grants and
donations from local and State governments or private sources.
14
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 non-patient care dining services, grants,
bad debts, any gains or losses on investments and contractual obligations.
Recipients were not allowed to use PRF payments to pay any salary at a rate in excess of Executive Level II, which
15
was set at $197,300 for 2020 and $199,300 for 2021.
Home Health Agencies’ Compliance With Provider Relief Fund Requirements (A-01-22-00503) 5
payments (i.e., preaward costs dated back to January 1, 2020).16 HHAs 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, HHAs 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 net patient care revenues and 2019 actual net patient care revenues, (2) the
difference between budgeted patient care revenues (approved by HHA officials prior to March
27, 2020) and actual patient care revenues, or (3) any reasonable method of estimating
revenues. 18
HRSA guidance for the treatment of unallowable or ineligible expenditures of PRF funds states
that providers could 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 $209.6 million in PRF Phase 1 General Distribution payments and related
interest to a non-statistical sample of 25 HHA taxpayer identification numbers (TINs) during
calendar year (CY) 2020.19 (We refer to these sample units throughout the report as “HHAs.”) 20
The selected HHAs reported that they used $108.7 million of their PRF payments to offset lost
16
HRSA, Provider Relief Fund Distributions and American Rescue Plan Rural Distribution Post-Payment Notice of
Reporting Requirements (PRF Reporting Requirements).
17
The period of availability ends 1 year after the end of the period in which the payment was received. The first
payment receipt period was April 10, 2020, through June 30, 2020. Subsequent payment receipt periods were 6
months.
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, which was the end of the quarter in which the COVID-19 Public
Health Emergency ended (HRSA Notice of PRF Reporting Requirements). Accessed on November 21, 2024.
19
Some HHAs kept their PRF payments in an interest-bearing account and included interest in the amounts
reported on expenditure reports submitted to HRSA.
20
The sampling frame consisted of 9,578 HHAs that received and kept 1 or more PRF payments totaling
approximately $13.6 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 HHAs that received PRF
payments issued in CY 2020 and for which HHAs attested to the payment terms and conditions or were deemed to
have accepted the terms and conditions.
Home Health Agencies’ Compliance With Provider Relief Fund Requirements (A-01-22-00503) 6
revenues, $58.8 million for general and administrative expenses, and the remaining $42.1
million for health care-related expenses. 21 Appendix E contains details on how the selected
HHAs used PRF payments issued in CY 2020.
We selected HHAs based on an analysis that considered the amount of PRF payments received,
geographic location, and organizational structure (e.g., HHA groups and stand-alone HHAs). 22
We reviewed the HHAs’ 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 HHAs that reported expenditures, we reviewed a non-statistical sample of expenses
that we selected based on materiality and expense descriptions (e.g., salaries, supplies,
equipment). For the selected HHAs that reported lost revenues, we reviewed the HHA’s lost
revenue calculations.23
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
The selected HHAs complied with terms and conditions and Federal requirements for
expending PRF funds, including 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 attributable
to COVID-19; (3) not used to reimburse expenses or losses that have been 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. The HHAs used the funds for allowable general and
administrative and health care-related expenditures attributable to COVID-19 and to offset lost
revenues attributable to COVID-19.
21
HHAs reported these amounts on expenditure reports submitted to HRSA for reporting periods 1 and 2.
22
Our sample unit was a HHA that reported the use of PRF General Distribution payments. Each sampled HHA
could be a stand-alone HHA or part of a parent-subsidiary system that may include a parent company and other
provider types (e.g., hospice). The 25 selected HHAs each received PRF payments from $1.5 million to $99.6
million during CY 2020 and are located in 10 states. 12 of the HHAs are stand-alone HHAs and 13 are part of HHA
groups.
23
Of the 25 selected HHAs, 14 HHAs reported both expenses and lost revenues, 6 HHAs reported only expenses,
and 5 HHAs reported only lost revenues.
Home Health Agencies’ Compliance With Provider Relief Fund Requirements (A-01-22-00503) 7
Example: One HHA’s Use of PRF Payments
For example, one of the selected HHAs received PRF payments of $1,287,322, of which it
reported to HRSA that it applied $918,325 to offset lost revenues and used the remaining funds
for health care-related and general and administrative expenses. Our review of the HHA’s
accounting records showed that lost revenues were correctly calculated based on the
difference between actual net patient care revenues (i.e., difference between 2019 and 2020
actual net patient care revenues). The HHA included only eligible patient care service revenue
attributable to COVID-19 in its calculation. The HHA’s accounting, personnel, and other records
also showed that the total reported expenses of $368,997 were used for purposes attributable
to COVID-19. Specifically, the HHA used $267,221 of its PRF payments for general and
administrative expenses that included personnel costs such as COVID-19 related sick pay,
employee retention bonuses, and hiring bonuses. Additionally, the records showed that the
HHA used $101,776 of its PRF payments for health care-related expenses that included PPE
(e.g., gowns and masks).
CONCLUSION
The 25 selected HHAs complied with terms and conditions and Federal requirements for
expending PRF funds. Accordingly, this report does not contain recommendations.
Home Health Agencies’ Compliance With Provider Relief Fund Requirements (A-01-22-00503) 8
APPENDIX A: AUDIT SCOPE AND METHODOLOGY
SCOPE
We identified 9,578 unique TINs related to HHA providers that received and kept Phase 1
General Distribution payments during CY 2020 totaling approximately $13.6 billion. We
selected for audit a non-statistical sample of 25 HHAs that received PRF payments from General
Distributions totaling $209.6 million during CY 2020. 24 We selected HHAs based on a risk
analysis that considered the amount of PRF payments received, geographic location, and
organizational structure (e.g, HHA groups and stand-alone HHAs). We reviewed the HHA’s PRF
payments used to offset lost patient care revenues and/or cover general and administrative
and health care-related expenses. We reviewed the selected HHAs’ use of PRF payments
received from General Distributions.
We limited our review of HRSA’s and the selected HHA’s internal controls to those applicable to
our audit objective. We did not assess HRSA’s or the HHA’s 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 HHAs’ 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 HHAs submitted through HRSA’s PRF Reporting
Portal.
We conducted our audit from November 2021 to November 2024.
METHODOLOGY
To accomplish our objective, we:
• reviewed applicable Federal laws, regulations, and guidance, including the PRF terms
and conditions and HRSA’s FAQs related to providers’ use of PRF payments;
• met with HRSA officials to gain an understanding of the PRF’s payment terms and
conditions, reporting requirements, and HRSA’s monitoring and oversight activities;
24
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 HHAs that received PRF payments issued in CY 2020 and
for which HHAs attested to the payment terms and conditions or were deemed to have accepted the terms and
conditions.
Home Health Agencies’ Compliance With Provider Relief Fund Requirements (A-01-22-00503) 9
• 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;
• obtained PRF payments data for Phase 1 General Distributions in 2020;
• compiled a list of 9,578 HHAs that received and kept Phase 1 General Distribution PRF
payments in 2020;
• selected a nonstatistical sample of 25 HHAs that received and kept PRF payments based
on the amount of PRF payments received, geographical location, and organizational
structure (HHA groups and stand-alone HHAs);
• for each HHA selected, interviewed HHA officials; reviewed its expenditure reports
submitted to HRSA and a non-statistical 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 used for health care-related expenses, general and administrative
expenses, or applied to offset eligible lost revenues attributable to COVID-19,
and that the amount for any lost revenues applied toward PRF payments was
accurately calculated; 25
o payments were not used to pay for expenses or losses reimbursed or eligible for
reimbursement from other funding sources (i.e., reimbursements from the
Federal Emergency Management Agency, Medicare/Medicaid or commercial
health insurance, Paycheck Protection Program, and assistance from State or
local government agencies); and
o payments were not used to pay salaries at a rate in excess of certain thresholds
or for other prohibited activities; and
• discussed the results of our audit with HRSA officials.
We shared our draft report with HRSA, and it informed us that it did not have comments other than
technical comments, which we addressed as appropriate.
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
25
We recalculated lost revenue amounts using the same option that the entity used for determining lost revenues.
Home Health Agencies’ Compliance With Provider Relief Fund Requirements (A-01-22-00503) 10
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.
Home Health Agencies’ Compliance With Provider Relief Fund Requirements (A-01-22-00503) 11
APPENDIX B: RELATED OFFICE OF INSPECTOR GENERAL REPORTS
Date
Report Title Report Number
Issued
Seven of Thirty Hospices Reviewed Did Not Comply or May Not
Have Complied With Terms and Conditions and Federal A-02-22-01014 11/8/2024
Requirements for Provider Relief Fund Payments
HRSA Made Some Potential Overpayments to Providers Under
the Phase 2 General Distribution of the Provider Relief Fund A-09-22-06001 3/4/2024
Program
The Provider Relief Fund Helped Select Nursing Homes
Maintain Services During the COVID 19 Pandemic, but Some OEI-06-22-00040 12/12/2023
Found Guidance Difficult to Use
HHS’s Oversight of Automatic Provider Relief Fund Payments
A-02-20-01025 10/30/2023
Was Generally Effective but Improvements Could Be Made
HRSA Made COVID-19 Uninsured Program Payments to
Providers on Behalf of Individuals Who Had Health Insurance A-02-21-01013 7/13/2023
Coverage and for Services Unrelated to COVID-19
Targeted Provider Relief Funds Allocated to Hospitals Had
Some Differences With Respect to the Ethnicity and Race of OEI-05-20-00580 7/12/2023
Populations Served
HHS’s and HRSA’s Controls Related to Selected Provider Relief
A-09-21-06001 9/26/2022
Fund Program Requirements Could Be Improved
Home Health Agencies’ Compliance With Provider Relief Fund Requirements (A-01-22-00503) 12
APPENDIX C: PROVIDER RELIEF FUND GENERAL AND TARGETED DISTRIBUTION PAYMENTS
As of February 2024, HRSA distributed $145.9 billion of the $178 billion appropriated to the
PRF. 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
has been distributed or allocated for HRSA’s program for uninsured individuals, the COVID-19
Coverage Assistance Fund, and Phase 4 General Distribution payments. 26
General Distributions
HRSA made General Distributions in four phases to health care providers, including Medicare
providers; providers participating in Medicaid, the 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' share 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 revenues 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 revenues in PRF assistance were also
eligible to apply for additional funds. Providers were required to apply for these funds.
• Phase 4 General Distribution: HRSA distributed approximately $15.6 billion in the Phase
4 General Distribution to providers based on changes in revenues and expenses as well
as the amount and type of services provided to Medicare, Medicaid, and/or CHIP
patients. Providers were required to apply for these funds.
26
As of June 2023, with the passage of the Fiscal Responsibility Act of 2023, P.L. No. 118-5, Congress rescinded
some unobligated PRF payments. In response, HRSA stopped making PRF payments to providers.
Home Health Agencies’ Compliance With Provider Relief Fund Requirements (A-01-22-00503) 13
Targeted Distributions
HRSA also distributed PRF funds to target certain types of providers that had high needs due to
COVID-19. These included the following:
• COVID-19 High-Impact Area Distributions: HRSA distributed nearly $22 billion in COVID-
19 high-impact area payments to hospitals that had large numbers of COVID-19
inpatient admissions.27
• Safety Net Hospitals and Children’s hospitals: HRSA distributed $13.3 billion to safety net
hospitals and acute care hospitals and $1.1 billion to children’s hospitals.
• Rural Distributions: 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 Provider
Payments: HRSA distributed $540 million in relief funds to the tribal hospitals, clinics,
and urban health centers. These payments were based on operating expenses.
• Skilled Nursing Facilities and Nursing Homes Payments: 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.
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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.
Home Health Agencies’ Compliance With Provider Relief Fund Requirements (A-01-22-00503) 14
APPENDIX D: OPTIONS FOR CALCULATING LOST REVENUES
Providers, including HHAs, could use one of the following three options to calculate their lost
revenues.
Table: Options for Calculating Lost Revenues
Lost
Revenues
Options Option 1 Option 2 Option 3
The difference
The difference between
between actual Any reasonable method
Definition of budgeted and actual
patient care of estimating revenues
Option patient care revenues
revenues
PRF Reporting Alternate Reasonable
2019 Actual Revenue 2020 Budgeted Revenue
Portal Option Methodology
Base Period for
2019 2020 or 2021 Not prescribed
Calculation
Actuals vs. Actuals
Calculation
(e.g., Q1 2020 vs. Q1 Budget vs. Actuals Not prescribed
Method
2019)
Frequency of
Quarterly Quarterly Quarterly
Calculation
Duration of Each quarter during the
Lost Each quarter during the Each quarter during the period of availability in
Revenues period of availability period of availability which lost
Period revenues were determined
Service Lines to All patient care services
Include in All patient care services All patient care services (as appropriate for
Revenues methodology)
Budget
Not applicable Before March 27, 2020 Not prescribed
Approval Date
Source: HRSA, Provider Relief Fund Lost Revenues Guide – Reporting Period 1, August 2021. Accessed on
July 26, 2024.
Home Health Agencies’ Compliance With Provider Relief Fund Requirements (A-01-22-00503) 15
APPENDIX E: SELECTED HOME HEALTH AGENCIES’ REPORTED USE OF CY 2020 PROVIDER
RELIEF FUND PAYMENTS
Home Health Agencies’ Compliance With Provider Relief Fund Requirements (A-01-22-00503) 16
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