For all the complaints about managed care, its prevention-focused mission has made at least this subterfuge obsolete. What bothers many physicians is that today's rules often don't make the slightest sense to them. Susan Buttross, a pediatrician in Jackson, Miss., who also teaches at the University of Mississippi Medical School, says she frequently has trouble getting health plans to approve speech therapy unless it results from an accident or injury rather than a congenital condition. I'd say they're approved about 50 percent of the time. Some health plans know something's going on.
Empire also compares diagnoses with many patients' prescribed medications to see if they match.
The group that represents managed-care plans accepts some responsibility for these games. So far, the legal consequences for physicians appear to be minimal. Both put the doctor in a bind, ethically and legally. When a patient asks me to put down a condition that isn't covered, I say I'm willing to appeal. What patients can do is to ask physicians directly to be their advocates.