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 wants to explore and enter into a different domain for testing, learn and understand healthcare 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 the Healthcare domain.

How To Test Health Care Application

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

Healthcare Domain- An Introduction

Health Care or Health Insurance is similar to general insurance. As you know, in any insurance, the insurer (Insurance company) will provide the plans and the customer (Subscriber or Policyholder) will buy the policy of his desired plan. The insurer will receive the premium amount from the policyholders and the policy Holders will get reimbursements from the insurer for the valid claims they have submitted.

The same happens in healthcare insurance but in addition to insurer and policyholder, 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 that creates a plan, sells the policy and reimburses policyholder or provider for the submitted valid claims.

#2) Policy Holder: A person or an entity, who buys the policy from the insurer or broker, pays a premium to the insurer and sometimes submits a claim.

Healthcare policy holder

#3) Provider: A person or an entity, which provides the healthcare service to the policyholder and their dependents, either receive payment for the service from the policyholder or the insurer by submitting a claim.

#4) TPA: A person or an entity that manages the claims of the policyholder or provider and receives payment for the management from the respective contributor.

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

Healthcare insurance broker

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

Mr. Enosh bought a health care policy that covers general physician consultation and vision problems from Mr. Ponnar and pays a premium for the same to a healthcare 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 a 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 policyholder, 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 ( an instance of the class). A policy can be categorized as individual policy and group policy based on the type of beneficiaries it covers.

Individual Policy: An individual will be the policyholder; 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 policyholder, the members (Employees) of the entity and their dependents will enjoy the benefits of the health plan. Here the entity pays the premium.

For 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 policyholder, HealthCorp Company is the Insurer and EasyCliam Company is the TPA.

How To Test a Healthcare Application?

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

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 policyholder data, various plans with their list of benefits and generate premium bills for the policyholder 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 policyholder information, make premium payments and raise a request for change information for policyholders
  • Provider portal: To display provider information and raise a request for change information for providers
  • Broker portal: to display broker information and raise a 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, the Provider system can be part of the Member system in some healthcare applications. By Healthcare application, I mean a set of systems maintained by an Insurer to facilitate their customers and partners.

Health Care Application Testing Workflow

The unique feature of the Health Care system is that these applications cannot be tested in any order we like. There is a certain workflow to be followed:

  • For a member/policyholder to be enrolled in a health plan he/she needs to be assigned to a provider (Primary Care Physician) or a provider network, so there should be a way for the member system to validate the assigned provider. Either member system connects to the provider system or a data feed should periodically send to member system from provider system. Therefore the provider system should be tested and ready to use before testing the member system.
  • A claim should consist of provider ID and member ID in addition to other details. The claim system should validate both the member and provider to validate the claim, so both member and provider system should be tested and ready to use before testing the claims system.
  • The finance system needs to have data from a 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.

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 Healthcare applications, which will be dealt with in the 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 meantime, if you have any questions 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.

Recommended Reading

50 thoughts on “How To Test Health Care Application – Part 1”

  1. 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 and @ Anuradha,

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

  3. 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 )

    Prasad Bhavanasi

  4. 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.

  5. 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

  6. 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.

  7. 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

  8. 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

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

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

  11. @ 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.

  12. 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.


  13. 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.

  14. @ 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.

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

  16. This is basically about health insurance but what about various application used for health care services & various health care app.

    Any details on testing those type of health care application?

  17. In healthcare there are different areas to be tested.
    could be in insurance are or hospital are(inpatient,Outpatient ,observation and ER)
    the insurance is used in different ways and billing is also done in different ways.
    There are Various applications used as Epic,Allscript,Aurora,meditech etc.Each applications are used for different purposes.While you are using this applications,you need to have the understanding of basic billing and claims.Primary and secondary insurances.The HCPC codes how many digits and the HIPPA regulations.Medicare and medicaid understanding and how its being used as a Medicare advantage plan

  18. I am working for US Health Care Services in Insurance claims processing , Please provide me more information and regular updates to my mail Id …Thanks

  19. I am a medical biller and hope to land a job in this domain as I feel I know it pretty well! Glad to have come across this article


Leave a Comment