Last-minute efforts to reach agreement on policy to ban surprise medical bills have slowed amid a multi-front lobbying push by healthcare providers and conservative groups.
Talks on surprise billing revived in the House over the weekend, but lawmakers haven't reached an agreement on an issue that has stubbornly divided both Democrats and Republicans for more than a year, according to lobbyists and staff familiar with the conversations.
Talks of tweaking surprise billing legislation to appease provider-friendly lawmakers have been simmering since summer, but the changes weren't enough to win over skeptical stakeholders. Eighteen physician groups, including the American Medical Association, sent lawmakers a letter stating that tweaks to allow providers to batch claims in dispute resolution processes and allow arbiters to consider prior contracted payment rates didn't win their support.
"We have concerns that the new proposal does not provide a fair process to resolve payment disputes between insurers and physicians. It continues to harm physicians and our patients to the benefit of insurers," the groups wrote in October.
The American Hospital Association last week warned that talks could resume amid negotiations on year-end spending legislation, and made clear its adamant opposition to the existing deal.
"We oppose legislative proposals that set a default payment rate for out-of-network services. While no legislative language has been provided, we understand the proposal would include a prohibition on balance billing and rely on rate setting to establish an initial payment, with an opportunity for providers to dispute the payment," the AHA said in a fact sheet released Dec. 3.
Action came to a head over the weekend as House Speaker Nancy Pelosi's (D-Calif.) office tried to convince Ways & Means Chair Richard Neal (D-Mass.) to find a way to reconcile his policy differences with an approach backed by several other powerful House and Senate committees.
But provider lobbyists said they have been skeptical of more attractive offers that haven't been accompanied by legislative text.
A Ways & Means Committee spokesperson said Neal has repeatedly asked that legislative text of other committees' latest proposal be made public.
"The Chairman wants to find a balanced path forward on this issue that prioritizes patients but also treats fairly community doctors and hospitals that have been completely overwhelmed by the COVID crisis," the spokesperson said.
A senior congressional committee aide said that the Ways & Means Committee had been provided with bill text of a prior agreement in July, but not of the more recent offer, which the aide described as a "pretty dramatic concession" to Neal.
State-based provider groups scrambled to head off the legislation in the Senate.
With upcoming elections in January in Georgia, GOP Sens. David Perdue and Kelly Loeffler are defending battleground seats that will decide control of the Senate. The Medical Association of Georgia said it didn't comment on specifically on provisions under discussion this week, but outlined the group's policy priorities generally.
"We also emphasized the need for lawmakers to take enough time to ensure that any legislation won't harm physicians or destabilize the health care system," said Medical Association of Georgia spokesman Tom Kornegay.
Aides and lobbyists said that the Greater New York Hospital Association likely made its views on the surprise billing deal's progress known to Senate Minority Leader Chuck Schumer (D-N.Y.), but both GNYHA and Schumer declined to comment on the issue.
Senate Minority Leader Mitch McConnell (R-Ky.) has not been enthusiastic about the issue, and the Kentucky Hospital Association has stated that it prefers a solution that allows insurers and providers to negotiate payment rates. The Kentucky Hospital Association did not respond to an inquiry on whether it has reached out to McConnell on the issue in recent days.
McConnell has balked at surprise billing reform so far because it divides his caucus, and five GOP senators sent him a letter on Dec. 4 staking out their opposition to including surprise billing reform in year-end legislation.
"Short circuiting the Senate's work on this topic by including rate setting in a must pass end-of-year legislative vehicle will leave patients with fewer choices, and will embolden those who believe the federal government should manage complex health care matters," wrote Sens. Marsha Blackburn (R-Tenn.), Ron Johnson, (R-Wisc.), Roger Wicker (R-Miss.), Rand Paul (R-Ky.) and Mike Lee (R-Utah).
In some ways dynamics are similar to last year's December surprise billing fight, when a similar group of leaders failed to tack surprise billing onto appropriations legislation.
"They tried to run the same outdated strategy they did last year and got beat again," a provider lobbyist said.
However, 2020 has altered the calculations somewhat. Some had hoped that Sen. Lamar Alexander's (R-Tenn.) retirement would soften McConnell toward his legacy issue, though the prospect looks unlikely. House Democrats are also facing a much narrower majority next Congress, which will make it harder to muscle through controversial healthcare legislation.
Lawmakers are negotiating ahead of an expected Dec. 18 government funding deadline.