Health insurance can be confusing—even for people who work in healthcare! Our goal is to help you understand how your insurance works, so there are fewer surprises when you receive care.
We created this Insurance Education Center to provide easy-to-understand information about common insurance terms, billing processes, and healthcare benefits. Whether you're trying to understand your deductible, compare different types of insurance plans, or learn why you received a bill, our goal is to give you the knowledge and tools you need to make informed decisions about your healthcare.
Understanding your insurance benefits before receiving care can help you:
Please remember that every insurance plan is different—even plans offered by the same insurance company may have different benefits, deductibles, copays, coinsurance, provider networks, and coverage rules.
We believe patients deserve clear, transparent information about their healthcare and insurance benefits. While we can't change the rules set by your insurance company, we are committed to helping you understand the billing process, answering questions about the services we provide, and offering educational resources that support informed healthcare decisions.
A copay is a fixed amount you pay for certain healthcare services, such as an office visit.
Your copay is collected at the time of your appointment.
A deductible is the amount you must pay each year before your insurance begins sharing the cost of many services.
Until your deductible is met, many services may be your responsibility.
Once your deductible has been met, many plans require you to pay a percentage of the remaining cost. This is called coinsurance.
Insurance pays 80% of their allowed amount; you pay the remaining 20%.
This is the most you'll pay for covered medical expenses during your plan year. Once you reach this amount, your insurance generally pays 100% of covered services for the remainder of the year.
If your insurance plan covers more than one family member, it may have both individual and family deductibles and out-of-pocket maximums. Understanding the difference can help you better estimate your healthcare costs throughout the year.
An individual deductible is the amount one covered family member must pay toward covered healthcare expenses before insurance begins sharing the cost of many services for that individual.
A family deductible is the total amount that all covered family members combined must pay before the deductible is considered met for the family. Medical expenses paid by multiple family members generally accumulate toward the family deductible.
| Family Member | Expenses Paid Toward Deductible |
|---|---|
| Parent 1 | $2,000 Individual deductible met |
| Parent 2 | $500 |
| Child | $1,500 |
| Family Total | $4,000 Family deductible met |
Sample figures for illustration only—your plan's amounts will differ. If one family member incurs $2,000 in covered medical expenses, that person may begin receiving benefits subject to the terms of the plan (such as coinsurance), even if the family deductible has not yet been met. This depends on your plan design.
Once the family deductible has been met, covered family members may begin receiving benefits according to the terms of the plan.
The individual out-of-pocket maximum is the most one covered person will pay during the plan year for covered services, including deductibles, copays, and coinsurance (subject to plan rules). After reaching this limit, the insurance company generally pays 100% of covered in-network services for that individual for the remainder of the plan year.
The family out-of-pocket maximum is the combined limit for all covered family members. Once the family reaches this maximum, the insurance company generally pays 100% of covered in-network services for all covered family members for the rest of the plan year.
Insurance plans vary in how deductibles are applied.
If you're unsure how your plan works, contact your insurance company or review your Summary of Benefits and Coverage (SBC).
Health Maintenance Organization
Preferred Provider Organization
Point of Service
A combination of HMO and PPO features. You may need referrals for some services while still having some out-of-network coverage.
This topic is one many patients have never heard of, or at least aren't very familiar with.
Many insurance companies have different provider tiers or benefit levels within their network. This means that even if two providers are both considered in-network, your out-of-pocket costs may be different depending on your insurance plan.
| Provider Tier | Typical Copay | What It Means |
|---|---|---|
| Tier 1 — Preferred | $25 | Lowest out-of-pocket cost within the network |
| Tier 2 — Standard | $45 | Still in-network, moderate cost-share |
| Tier 3 — Non-Preferred | $75 | In-network, but highest cost-share within that network |
Sample tier names and amounts for illustration only. Your insurance company assigns the actual tiers and costs for your specific plan.
Some insurance plans also offer:
These designations are determined by your insurance company—not by our medical practice.
Depending on your insurance plan, provider tiering may affect:
Before your appointment, we recommend contacting your insurance company to ask:
Knowing these answers before your visit can help prevent unexpected expenses.
Depending on your insurance plan and the services provided, visits performed by one of our Nurse Practitioners (NPs) or Physician Assistants (PAs) may be billed under the supervising physician in accordance with applicable payer requirements and billing guidelines.
As a result, your Explanation of Benefits (EOB) or insurance claim may list a supervising physician's name instead of the provider you saw during your visit.
Sample structure only. Practice team: replace with your practice's actual supervising physician and associated NP/PA assignments.
| Term | Definition |
|---|---|
| HDHP High-Deductible Health Plan | A High-Deductible Health Plan is a deductible plan with no copay. |
| HSA Health Savings Account | A savings account that allows patients with an HDHP to set aside pre-tax money to pay for eligible healthcare expenses. Funds generally roll over year to year and remain with you even if you change employers or insurance plans. |
| HRA Health Reimbursement Account | An employer-funded account that reimburses employees for eligible healthcare expenses. The employer determines the contribution amount, eligible expenses, and whether unused funds carry over to the next calendar/policy year. |
| FSA Flexible Spending Account | An employer-sponsored account that allows employees to set aside pre-tax money to pay for eligible healthcare expenses. Many FSA plans have a "use it or lose it" rule, although some plans may allow limited carryover or a grace period depending on employer plan rules. |
Why didn't insurance pay my entire bill?
Your insurance processed the claim according to your individual policy benefits, deductible, copay, coinsurance, and coverage rules.
Why did I get a bill after paying my copay?
This is one of the most common questions we receive. Your office visit copay generally covers only the provider's evaluation during your appointment. Additional services are often processed separately by your insurance, including:
These services may apply toward your deductible and/or coinsurance.
Why do I receive a bill weeks after my visit?
Your insurance must first process the claim before we know your full patient responsibility.
Can your office tell me what my insurance will pay?
Unfortunately, no. We can estimate your costs, but your insurance company makes the final determination after processing your claim.
Why do I have to update my insurance every visit?
Insurance plans, subscriber information, and coverage often change throughout the year. Keeping your information current helps prevent claim delays.
Why do I owe money if my insurance "covered" the visit?
Insurance may have applied part of the cost to your deductible, coinsurance, non-covered services, or out-of-network benefits.
Many insurance plans cover annual wellness or preventive visits at little or no cost.
If your provider evaluates a new medical problem, orders testing for symptoms, or treats an illness during the same visit, those additional services may be processed as diagnostic care under your insurance benefits. Examples include:
Diagnostic services may be subject to deductibles, copays, or coinsurance even when performed during your annual wellness exam.
Some tests and services performed during your visit are processed by independent companies, not by our medical practice. These companies bill your insurance separately and send their own statements if you have a balance. Examples include:
Other specialized laboratories or diagnostic service providers may be used by your provider, or you as the patient may choose to use a specialized lab or diagnostic center of your own choosing. Because these organizations are separate from our practice, you may receive a bill directly from them.
If you believe your laboratory or third-party bill was processed incorrectly due to a coding issue:
Contact your insurance company if you have benefit questions.
If your account has been placed with a third-party collection agency, future payments and account questions may need to be directed to that agency. We partner with a third-party vendor for outstanding balances we were unable to collect internally. See below for the collection agency information:
G & G Recovery
888-779-3996
gandgrecovery.com(opens in a new tab)
Monday–Friday, 9:00 AM–5:00 PM
If you believe your account was sent to collections in error, or if you have questions regarding services received at our practice, please contact our office during normal business hours. We are happy to review your account and assist whenever possible.
We're here to help! Depending on your question, different members of our team may assist you.
For questions about:
706-692-9768 (Option 4 for Billing)
For questions about:
For questions about:
This resource hopefully empowers you, our patients, to get answers faster. Short videos on the topics above will appear here.
Placeholder slots — swap each with an embedded reel (e.g. an <iframe> or <video> element) once produced.