Health Law Daily Wrap Up, COVID-19—PRRB DECISIONS: Hospital’s deficient COVID-19 vaccination reporting triggers Medicare payment reduction, (Sep 15, 2026)

By Ravindra Kumar Singh, B.L.

The record did not establish that required healthcare personnel data had reached the designated reporting system by CMS’s quarterly deadline.

The Provider Reimbursement Review Board (PRRB) upheld CMS’s decision to reduce an acute care hospital’s fiscal year (FY) 2024 annual payment update (APU) by one-fourth for failing to comply with Hospital Inpatient Quality Reporting (IQR) Program requirements. The Board found that Broward Health North failed to establish that it timely submitted required COVID-19 Vaccination Coverage Among Health Care Personnel (HCP) data for the third quarter of 2022. Data characterized as corrected was not submitted until after the February 15, 2023, deadline, and the record did not establish what, if anything, had actually been entered into the required reporting system before that deadline (Broward Health North v. First Coast Service Options, Inc., PRRB Dec. No. 2026-D25, Case No. 24-0153 (Aug. 25, 2026)).

Quality reporting requirements. Under the Hospital IQR Program, hospitals must submit specified quality-of-care data in the form, manner, and at the time prescribed by the HHS Secretary. Hospitals satisfying the requirements receive the full annual increase in their standardized inpatient prospective payment system amount. Failure to report required quality data results in a one-fourth reduction to the applicable market-basket percentage increase under 42 C.F.R. § 412.64(d)(2)(i)(C).

For FY 2024, hospitals were required to report COVID-19 HCP vaccination data through the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN). Hospitals had to collect numerator and denominator information for at least one self-selected week during each month of the quarter. Hospitals had to submit third-quarter 2022 data, covering July through September, by February 15, 2023.

CMS informed Broward in March 2023 that it had failed to meet the reporting requirement and would therefore receive a one-fourth APU reduction. The agency upheld that determination on reconsideration. The hospital then appealed to the PRRB.

Corrected data. Broward maintained that it originally submitted July 2022 vaccination data through NHSN in August 2022. It later discovered that the information did not account for an updated definition of healthcare personnel considered up to date with COVID-19 vaccinations. The hospital said it discovered the problem on February 17, 2023, and uploaded corrected information on February 27—both after the quarterly deadline.

The record did not substantiate Broward’s characterization of what had occurred. After requesting additional information, the Board compared the hospital’s spreadsheet said to contain the original data with the February 2023 corrected submission. Among other differences, the later version changed the data-collection period and increased certain healthcare personnel counts.

Significantly, the number of healthcare personnel identified as up to date with COVID-19 vaccines did not change. That undermined Broward’s contention that its original submission was deficient because it had failed to account for the updated vaccination definition incorporating booster doses. The differences also did not show that the original data was merely incomplete rather than incorrect for another reason.

More fundamentally, the only actual NHSN screenshot in the record concerned the February 27 corrected data. Broward’s other exhibits consisted of an Excel spreadsheet and a PDF version of spreadsheet data. Neither demonstrated that any information—accurate or inaccurate—had actually been reported through NHSN before the February 15 deadline.

No notification obligation. Broward also contended that CMS or NHSN should have notified it about inaccuracies so that the hospital could correct them before the deadline. The Board disagreed. Guidance cited by the hospital stated that the NHSN team conducted outreach to facilities that had not reported any data during a reporting month. It did not establish an obligation to examine submitted information for accuracy and notify hospitals of errors.

Indeed, Broward’s own internal communications showed that staff recognized in August 2022 that certain employee counts did not match and that NHSN would not accept the information unless the relevant totals corresponded. Nevertheless, the evidence still did not demonstrate that corrected information reached NHSN before the reporting deadline.

Notice and comment. The Board additionally rejected Broward’s argument that expanding the definition of a completed vaccination course to encompass booster doses constituted a substantive reimbursement change requiring additional notice-and-comment rulemaking under 42 U.S.C. § 1395hh(a)(2).

CMS had proposed the COVID-19 HCP vaccination measure through notice-and-comment rulemaking in the FY 2022 IPPS/LTCH proposed rule. In responding to comments concerning evolving vaccination recommendations, the agency expressly explained that the definition of a completed vaccination course was broad enough to encompass potential future booster doses. The Board therefore found no merit in the hospital’s procedural challenge. Moreover, because Broward had not established what it actually submitted in August 2022, it had not shown that the definitional change adversely affected that submission.

Accordingly, the PRRB found that Broward failed to submit its third-quarter 2022 COVID-19 HCP vaccination data in the form, manner, and time CMS required. It upheld the one-fourth reduction in the hospital’s FY 2024 APU.

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