(MONEY Magazine) – IT'S NOT EVERY DAY THAT A GROUP OF DOCtors says "Take this job and shove it" to a managed-care plan. So MONEY decided to investigate after we learned that 50 of 100 Tucson-area physicians had done just that when they were offered revised contracts by Intergroup of Arizona. What we found prompted Intergroup spokesman Sally Allison to ask us in exasperation: "What could I do to make you forget all about it?"

Our answer was "nothing." That's because the story of the doctors who quit Intergroup points up medically questionable practices that are widespread among managed-care companies. To make sure you get the best medical attention if you have managed care or are thinking of joining such a plan, here's what you need to watch out for:

General practitioners are being pressured to provide specialized care. Many managed-care firms are expanding the scope of their family doctorsÕ practices to save money on specialists' fees. For example, 14-year-old Intergroup, owned by Foundation Health of Sacramento, calls for G.P.s to reset dislocated shoulders and perform tracheotomies, among other tricky procedures.

Dr. Jane Heaton, an internist who refused to sign the Intergroup contract, had never performed several of the procedures listed in it despite a decade of practicing medicine. "Don't get me wrong. I'd attempt a tracheotomy if the patient was stuck at the bottom of the Grand Canyon," she says. "But in Tucson, it's not as if we don't have access to surgeons." Allison replies that Intergroup would never require a doctor to perform a procedure that he or she doesn't feel qualified to do.

Strong financial incentives exist to keep down referrals and shorten hospital stays. The new Intergroup contract set up potentially lucrative bonus pools for physicians who made fewer referrals to specialists than other doctors in the network. It also rewarded G.P.s who limited the number of days patients spent in the hospital. This kind of practice is widespread: 72% of network HMOs--the kind with contract doctors--reward physicians for keeping costs down, according to Mathematica Policy Research, a health-care consulting firm. Typically, the HMOs withhold 20% of the doctors' fees, letting them get the money back at the end of the year if they meet cost-cutting goals. Some health analysts say such incentives don't compromise the quality of care. But Dr. Steven Knope, an internist who also refused to renew his Intergroup contract, calls such bonuses "a built-in incentive to limit care."

Managed-care plans sometimes won't tell patients in advance whether a treatment will be covered. This has been a vexing problem for Judy Solis, whose health-care costs are covered by Intergroup and whose son Irineo Jr. has a port-wine stain--a congenital blood vessel deformity--on the right side of his face. Although it's common to remove port-wine stains with laser treatments, Solis had to file a grievance against Intergroup and fight for 11 months before the company let her seek such care for her son. Then, she says, Intergroup refused to tell her if it would pay for all the treatments necessary to remove the blemish. So she sued the company last August, demanding "reasonable" compensation for the delay her son faced in getting care. Intergroup denies any wrongdoing, and the case is pending.

While concern over such practices mounts, here's how to get topnotch care if you belong to a managed-care plan:

1. Find out how your doctor gets paid. You need to know whether your doctor has an incentive to limit care. Unfortunately, most managed-care contracts have gag clauses that prohibit doctors from discussing their compensation with patients. If your doctor wonÕt talk, get from your employer a copy of its contract with the plan.

2. Learn how qualified your primary-care doctor is to perform specialized procedures. For instance, if you break your arm, ask your doctor how many times he or she has reset fractures. If the answer is rarely or never, ask for a referral to a more experienced family doctor or to an orthopedist.

3. Get a second opinion. If you believe you're being denied necessary care, see another doctor immediately. Many managed-care plans pay for second opinions. There's another good reason for getting a second opinion: It could buttress your case if you decide to file a grievance against your plan.

--Karen Cheney