There are disagreements, however, about whether it's cheaper to have nurses handle cases on the phone or in the workplace itself. While Paduda thinks telephone case management can be more efficient, Carl Koch, the risk manager of United Natural Foods, wants to have the nurse on site. Working for the Danielson, Connecticut-based natural and organic food distributor, an outside nurse case manager coordinates treatment for injured workers at company facilities. "It's more costly, but the return on investment is significant as far as reducing lost time and medical benefits [expense]," says Koch.

The key to holding down those and other TPA-related charges is to have internal managers continually on the case, according to Koch. At United Natural, which is insured under a high-deductible plan, any claim that exceeds $5,000 is reviewed on a quarterly basis by the corporation's claims manager, its risk manager, and a human resources representative of the state in question. A representative of the company's insurance broker, RC Knox and Co., also takes a look.

Despite such vigilance, however, Koch feels the company must rely on a fair amount of faith in dealing with its TPA. While the company's contract with its administrator, ESIS Inc., demands full disclosure of fees or charges, Koch chooses not to delve too deeply into compensation issues. An employer has to have "a comfort level" in its relationship with its TPA, he says; "there has to be trust."

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