How to Test Health Care Application – Part 1


Understanding Health Care Domain and Testing Health Care Applications:

Today’s article is going to be all about healthcare- domain/business information, components, what to test and how to test.

This two-part article series is useful for anyone who want to explore and enter into different domain for testing, learn and understand health care application workflow and testing process.

In short, this article will be your first step and a guide on your healthcare knowledge quest.  In part 2 we will provide test scenarios for different applications under Healthcare domain.

To really excel in testing, domain knowledge is the key. So, we are going to learn the client’s business flow now.

how to test healthcare application

Health care domain- an introduction

Health Care or Health Insurance is similar to general insurance. As you know, in any insurance, insurer (Insurance company) will provide the plans and customer (Subscriber or Policy holder) will buy policy of his desired plan. Insurer will receive the premium amount from the policy holders and the policy Holders will get reimbursements from insurer for the valid claims they have submitted. The same happens in healthcare insurance but in addition to insurer and policy holder there are other major contributors such as provider, TPA (Third Party Administrator), broker, etc.

We will now see each of the major contributors in detail:

#1. Insurer:

An entity which creates plan, sell policy and reimburses policy holder or provider for the submitted valid claims.

#2. Policy Holder:

Healthcare policy holder

A person or an entity, who buys the policy from the insurer or broker, pays premium to the insurer and sometimes submit claim.

#3. Provider:

A person or an entity, which provides the health care service to the policy holder and their dependents, either receives payment for the service from the policy holder or from the insurer by submitting a claim.

#4. TPA:

A person or an entity that manages the claims of policy holder or provider and receives payment for the management from the respective contributor.

#5. Broker:

Healthcare insurance broker

As you have guessed, he is an agent who sells policy to the customers on behalf of insurer and receives commission in return from the Insurer.

Example: We can understand the basic function of contributors from the below example.

Mr. Enosh bought a health care policy which covers general physician consultation and vision problems from Mr. Ponnar and pays premium for the same to HealthCorp company. Once Mr. Enosh was sick and consulted the Physician Mr. Sabari for recovery, Sabari provided a prescription to Enosh and submits a claim for the consultation to HealthCorp Company and receives the reimbursement. Mr. Ponnar receives commission from HealthCorp Company for the payment of premium by Mr. Enosh.

In the above example ‘General Physician Consultation’ and ‘Vision Problems’ are the benefits of the health plan, Mr. Enosh is the policy holder, Mr. Ponnar is the broker, HealthCorp Company is the insurer and Mr. Sabari is the provider.

To clearly understand the difference between policy and plan, think plan as a class and policy as an object (instance of the class). Policy can be categorized as individual policy and group policy based on type of beneficiaries it covers.

Individual Policy:

An individual will be the policy holder; both the individual and his/her dependents will enjoy the benefits of the health plan. Here the individual pays the premium.

Group Policy:

An entity (Generally an employer) will be the policy holder, the members (Employees) of the entity and their dependents will enjoy the benefits of the health plan. Here the entity pays the premium.

Example: An example to have a clear idea of group policy is as follows,

MotoCorp Company buys a policy from HealthCorp Company for its employees and their family. Their claims are managed by EasyClaim Company. Here MotoCorp Company is the policy holder, HealthCorp Company is the Insurer and EasyCliam Company is the TPA.

How to test health care application?

Before testing an application, we should be aware of healthcare industry work flow. The previous topic just gives an introduction to managed health care, more details are available here.

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An Insurer needs different applications to manage the following:

  • Provider data
  • Member data
  • Premium billing/payment
  • Broker data
  • Claims entry/validation
  • Broker commission calculation/payment

Generally a healthcare application will have the following list of systems:

  • Member system – To maintain policy holder data, various plans with their list of benefits and generate premium bills for the policy holder based on their plans
  • Provider system – To maintain provider data
  • Broker system – To maintain broker data and calculate commissions
  • Claims system – For claim entry and validation
  • Finance system – To do the necessary payment to provider/member/broker
  • Member portal – To display the policy holder information, make premium payments and raise request for change information for policy holders
  • Provider portal – To display provider information and raise request for change information for providers
  • Broker portal – to display broker information and raise request for change information for brokers

This might not be an exhaustive list. But, this is the list to the best of my knowledge. Also, all applications might not even be used. Sometimes, few of these applications are merged to make another combination application- other times, these are stand-alone systems.

For example, Provider system can be part of Member system in some healthcare application. By healthcare application I mean a set of systems maintained by an Insurer to facilitate their customers and partners.

Health Care Application Testing Work flow

The unique feature of health care system is that, these applications cannot be tested in any order we like. There is a certain work flow to be followed:

  • For a member/policy holder to be enrolled in a health plan he/she need to be assigned to a provider (Primary Care Physician) or a provider network, so there should be a way for member system to validate the assign provider. Either member system connects to the provider system or a data feed should periodically sent to member system from provider system. Therefore provider system should be tested and ready to use before testing member system.
  • A claim should consist of provider ID and member ID in addition to other details. Claim system should validate both the member and provider in order to validate the claim, so both member and provider system should be tested and ready to use before testing claims system.
  • Finance system need to have data from member, provider, claim and broker system to write checks or make EFT payments to the respective person or entity.
  • Provider and broker systems are stand alone.
  • Portals should be tested at last since it needs data from the other applications.

(Click on image to enlarge)

Health Care Work flow

Now, that’s the order in which the systems in healthcare application should be tested.

What’s Next?

The above mentioned information should give us enough momentum to get into “How to test” the health care applications, which will be dealt with in the next 2nd part of this article.

About the Author: This is a guest post by Vairavan R M. Author is having good experience in testing Health Care Applications and leading a team in a Multinational corporation.

In the mean time, if you have any question or comments or need any help in understanding the Health Care domain better, please let me know. Stay tuned for the next article in the series.


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34 comments ↓

#1 Manoker on 03.17.14 at 10:43 am

Health care domain and Health Insurance or policy is different
Health insurance or policy related details are will come under Insurance related domain.

Health care is a full and full hospital related applications
Inpatient ,out patient Emergency dept and clinic related applications should be avilable

#2 Sameer on 03.17.14 at 10:49 am

Superb! Thanks for accepting my request to cover article on healthcare.

Waiting for the second part!

#3 Vairavan on 03.17.14 at 11:10 am

@ Manoker – Agree, we have taken Health insurance domain application as an example to get started in this domain!

#4 Dinesh on 03.17.14 at 12:13 pm

Hi i need sample project for testing ..with testing process overall..for putting in my project in resume

#5 Anuradha on 03.17.14 at 1:57 pm

I was waiting to understand Health Care Domain. Thanks for the post.

I will be waiting for part 2

#6 Vairavan on 03.17.14 at 3:30 pm

@Sameer and @ Anuradha,

Thanks for the comments. We will keep you posted on the date of publish of the second part of this article.

#7 Prasad Bhavanasi on 03.17.14 at 5:56 pm

My best Wishes and thanks for provided valuable information in part1 it self to all of them .

Even me also waiting for 2 nd part :-)

I hope it will cover ,
1. Mediclaim process
2.HMO (Health Maintenance Organisation )
3.PCP (Primary care Phycian)
4. PPO (Preffered provider organisation)process
5.HSA (Health Savings account)
6. CoPay,Co insurance.
7. COmplete Claim process (Its a big subject )

Thanks,
Prasad Bhavanasi

#8 Mel on 03.17.14 at 9:35 pm

This is good and important topic, I will be waiting for part 2.
Thanks for the post

#9 Ashok Akula on 03.17.14 at 11:34 pm

Most Interesting !!! waiting for part 2 !!! Thank you

#10 vishnu on 03.18.14 at 3:07 am

I’m working as test Engg with an EHR software which don’t have detailed functionality of providers/brokers.We are having modules like IP,OP,ER.Please include these workflows too.

#11 Madhu B on 03.18.14 at 4:22 am

Very good article. Expecting more in part 2

#12 bibhishan on 03.18.14 at 4:37 am

Nice article sir..

can i get the some examples of websites those are in health care domain ?

please sir

#13 udara on 03.18.14 at 4:49 am

Very good article….
waiting for part 2…

#14 Madhu B on 03.18.14 at 5:10 am

Hi,
In this article you have talked about insurance application, but there many more application in Health care. so pleas provide some generic information on health care

#15 Sujatha on 03.18.14 at 5:18 am

Kindly let me know the information about Gym products. i thought even Gym facility comes under Health Domain.kindly rectify ……Help me out with the application,test cases, and how to automate it.

#16 shruthi on 03.18.14 at 5:24 am

wow!!! This was awesome..very clear..can you provide the same structure of article with banking domain..i m intrested to know about that..anyways great

#17 Niraj on 03.18.14 at 5:38 am

This very help for who have less or no knowledge about health care domain. We all are waiting for the part -2 with more examples for web & mobile application. Nice work. Lots of thanks

#18 rocky on 03.18.14 at 6:05 am

very useful and explain by flow of process in health care domain. great presentation..Hope so with continous sharing of knowledge..@ Thanks vairavan

#19 Prashant Kumar on 03.18.14 at 6:50 am

Very informative.Can u please provide articles on Testing BFSI domain ?

#20 yashashwini on 03.18.14 at 8:08 am

Nice information , I would request to publish article on SAP functional (Finance , HR ect) as SAP is more complicated and interesting to know.

#21 Nitin on 03.18.14 at 8:58 am

Very good article

#22 Aishwarya on 03.18.14 at 10:35 am

Very informative.Can u please provide articles on MR Reporting System (Medical Representative) ?

#23 Swapna on 03.18.14 at 2:51 pm

Thank you for the post , waiting for Part 2.

#24 Vijay on 03.18.14 at 7:08 pm

@ all – thanks all for your comments and huge support.
The first article was mainly to introduce you to the healthcare domain (health insurance as an example). In second part we will explain how to test this application with test scenarios.

Also we got your inputs and soon we will provide more domain info (downloadable) on Healthcare, BFSI and other domains.

#25 Sujata on 03.19.14 at 9:49 am

Thanks for giving an idea about the Health Insurance Domain testing. Waiting for part 2….hope it will cover Health Care Domain (Hospital related) also.

Thanks

#26 vangasureshreddy on 03.19.14 at 9:52 am

Hi sir.This is suresh Reddy. Thanks for nice presentation.i got some knowledge after reading this part1.will wait for your part2 and future other domain . Thanks.

#27 VIKASH SINGH on 03.20.14 at 1:14 pm

I NEED A MANUAL TESTING LIVE PROJECTS ON INSURANCE DOMAIN AND SUPERB….POST…THKS

#28 raaj on 03.20.14 at 5:03 pm

I need help in understanding the Health Care domain better.

thx

#29 Vairavan on 03.20.14 at 9:39 pm

@ All,
Thanks for commenting.

#30 Vairavan on 03.20.14 at 9:45 pm

@ Prasad Bhavanashi
Hope you have read the second part, to explain the points you have mentioned takes much time. The main aim of this article is to give an introduction to health care domain and show a way to test the end to end flow of a health care application.
Sorry that I haven’t been detail but you can always go through the book that was mentioned in the article for more details.
Thanks

#31 divya on 03.25.14 at 4:09 pm

Please post a project about Banking domain asap.
How to test Banking application.

#32 divya on 03.25.14 at 4:16 pm

I want to know about Banking, Financial services and Insurance (BFSI) domain. How to test BFSI application.
Kindly post asap.

#33 Dolly on 03.31.14 at 10:02 pm

Can you please provide an understanding on testing on portfolio management project??

Thank you

#34 alo on 04.03.14 at 2:27 pm

is there anyone can help me how to write this project for the resume.Help will be appreciated.

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