'Surprise' billing fix to be included in spending package

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Congress is set to include a long-elusive ban on “surprise” medical bills as part of a major spending deal lawmakers were working to finalize Sunday evening.

A joint statement from House Speaker Nancy Pelosi and Senate Minority Leader Chuck Schumer confirmed a surprise billing fix is part of the government funding deal, which also includes $900 billion in new Covid-19 relief.

Though key congressional committees had agreed more than a week ago on a plan for protecting insured patients from large medical bills when they unwittingly receive out-of-network care, it had been unclear whether it would be part of must-pass government funding legislation. The final decision came down to Senate Majority Leader Mitch McConnell, who had been silent on the deal.

The White House has already endorsed the plan nearly two years after President Donald Trump first called on Congress to fix an issue that has drawn bipartisan concern. But those efforts were nearly derailed by opposition from well-funded groups and congressional turf battles.

While the health care industry agreed that patients should be held harmless in emergency situations, hospital and physician groups and insurers fought vigorously over who would pick up the tab. The compromise deal congressional committees struck earlier this month was considered largely a win for hospitals and doctors —and tweaks made in the final legislation are even friendlier to providers, according to a summary obtained by POLITICO.

What’s new: The previously announced deal called for health insurers and providers to negotiate most billing disputes or bring their complaints to a mediator. But in one key change, the final version of the bill would forbid arbiters from taking into account Medicare and Medicaid rates, which are typically much lower than what commercial coverage pays. That is a loss for insurers, employers who fund a major chunk of private coverage, and patient advocates who thought including those public rates as a barometer could help curb health care prices. As a guardrail, the measure also bars arbiters from considering providers’ billed charges, which are usually well out of line with what insurers or patients end up paying.

However, in a win for health insurers, lawmakers appear to have watered down a measure that would have required them to disclose detailed information to employers about their drug costs and rebates through their contracts with middlemen known as pharmacy benefit managers, whose business practices have come under scrutiny in recent years for their role in high drug costs. Instead, the legislation calls for insurers to submit more general information on medical costs and prescription drug spending to relevant federal agencies, which would feed into a government report on drug pricing trends.

Why it matters: Pressure has intensified on Congress to advance surprise billing protections in recent weeks, after two years of lobbying from powerful interest groups and policy fights stalled what was originally supposed to be an easy fix for this Congress.

The effort looked all but dead earlier this month, after another round of talks failed to bring House Ways and Means Committee Chair Richard Neal (D-Mass.) on board with a proposal other congressional committees had agreed on last year. But talks resumed again after Pelosi redoubled efforts to get Neal’s support for a fix.

For those supporting the surprise billing ban, the must-pass omnibus represents the last obvious opportunity to advance the legislation. Two of the key Republican champions of surprise billing legislation — Senate HELP Committee Chair Lamar Alexander of Tennessee and House Energy and Commerce ranking member Greg Walden of Oregon — are retiring this year.

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