Testing Healthcare Applications – Tips and Important Test Scenarios (Part 2)

In the last article, we did some heavy lifting in terms of understanding the healthcare domain. We are ready to put our “Tester’s hat” back on and now try to understand how to test the health care applications.

=> If you haven't read part 1 please read it here: How to Test Health care application – Introduction

We are now going to pick each application/system and come up with conditions that we are going to validate in each one of them.

This article is useful for the testers who are already in the Healthcare domain or those who want to enter in this hottest career field.

Testing Healthcare Applications

Let’s get started!

Healthcare Application Testing – The Sample Test Scenarios

This is the Sample Test Scenarios for:

Health Insurance System - Testing Components

Testing Of Provider System

#1) Provider System should be let us enter, edit and save provider data.

#2) Positive flow System testing: include scenarios to enter different types of Providers, change, save and inquire about them.

#3) Negative flow System testing: include scenarios to

  • Save a provider with incomplete data.
  • Save a provider with a contract effective date less than the provider license date.
  • Enter data of the provider which is already available in the system and save.

#4) System Integration testing should include scenarios to

  • Validate the feed to downstream systems such as the feed to Member system, Provider portal, Claim system, and Finance system.
  • Validate if the changes from the Provider portal are incorporated in the respective provider record.

Testing Of Broker System

#1) Broker System should be capable of the following:

  • Enter, edit and save broker data.
  • Calculate the broker commission based on the premium payment details from the member system.

#2) Positive flow System Testing should include scenarios to

  • Enter, edit and save broker record for different types of the broker.
  • Calculate the commission for the active broker by creating a feed file with the respective record for members with a different plan.

#3) Negative flow System Testing should include scenarios to

  • Enter a broker record with insufficient data and save for different types of the broker.
  • Calculate the commission for the terminated broker by creating a feed file with the respective record for members with a different plan
  • Calculate the commission for the invalid broker by creating a feed file with the respective record for members with a different plan

#4) System Testing should include scenarios to

  • Validate the feeds to the downstream systems such as the Broker portal, Finance system, and Member system.
  • Validate if the changes from the Broker portal are incorporated in the respective broker record.

Testing Of Member System

Member System should be capable of the following:

  1. Enroll, terminate, reinstate and re-enroll a member
  2. Add and remove a dependent
  3. Generate premium bill
  4. Process premium payments

Enrollment: In an Individual Policy, a policyholder is added under a plan with an effective date from which he/she will be paying a premium for the benefits provided by the insurer and from which he/she is eligible for submitting claims and receiving coverage.

In Group Policy, a member is added to the group (which is already added under a plan) with an effective date of which he/she is eligible for submitting claims and receiving coverage.

Termination: In an Individual Policy, the policy is terminated with a termination date of which a policyholder will not be covered by the insurance plan.

In Group Policy, either the member alone can be terminated with a termination date or the whole group can be terminated.

Reinstatement: If a terminated member asks for the policy to be active again and the current date is within the grace period from the termination date then the member can be reinstated without a gap in coverage. The policy effective date will be the same old effective date and not the current date.

Re-enrollment: If a terminated member asks for the policy to be active again and the current date is beyond the grace period from the termination date then the member can be re-enrolled with a gap in coverage. The policy effective date will be the current/future date and not be the same old effective date.

For Example, A member is enrolled in a policy with an effective date as 1/1/2013 and terminated on 12/31/2013. lets us take 30 days as the grace period fixed by the insurance company.

Case 1: If the member comes back on 1/15/2014 and wants the policy to be effective against then it is Reinstatement if the member pays the premium for the period 12/31/2013 to 1/15/2014 then the policy effective date will be the same old 1/1/2013.

Case 2: If the member comes back on 2/1/2014 and wants the policy to be effective again then it is Re-enrollment and the policy effective date will be 2/1/2014. Here there is a gap in coverage (1/1/2014 to 1/31/2014).

Positive flow System Testing should include scenarios to

  • Enroll different types of members with past, current and future effective dates.
  • Change and inquire about members.
  • Generate a premium bill for an active member for next month.
  • Terminate an active member with past, current and future termination date greater than the effective date.
  • Re-enroll a terminated member with past, current and future effective dates.
  • Reinstate a terminated member.

Negative flow System Testing should include scenarios to

  • Enroll a member with insufficient data.
  • Generate a premium bill for next month for a terminated member.

System Integration Testing should include scenarios to

  • Validate the feed to downstream systems such as Member portal, Provider portal, Broker system, Claim system, and Finance system.
  • Validate if the changes from the Member portal are incorporated in the respective member record.
  • Process the payment of a generated premium bill with the feed from the Member portal that has details of payment made.

Testing Of Claims System

Claims in healthcare have diagnosis code and procedure code for the claim to be in detail.

  • Diagnosis Code: Refers to the disease the patient had.
  • Procedure Code: Refers to the treatment provided to the patient.

Claims System should be capable of the following:

  • Enter, edit and process claims for the member as well as a dependent.
  • Should throw errors for invalid claims based on the incorrect data entered.

Positive flow System Testing should include scenarios to enter, edit and process claims for the member as well as a dependent.

Negative flow System Testing should include scenarios to

  • Enter and validate a claim with invalid diagnosis code and procedure code.
  • Enter and validate a claim with an inactive provider ID.
  • Enter and validate a claim with a terminated member.

System Integration testing should include scenarios to validate the feed to downstream systems such as finance and provider portal.

Testing Of Finance System

Finance System should be capable of writing paychecks and making EFT payments to the respective recipient by processing the feeds from various upstream systems such as claims, member, provider, and broker system.

Positive flow System Testing should include scenarios to check whether the correct address or account number is chosen for the respective provider, member or broker for the payment.

Negative flow System Testing should include scenarios to

  • Check whether payment is done for the invalid member, provider or broker ID by creating respective records in the feed.
  • Check whether payment is done for the invalid amount (Zero or negative) for the member, provider or broker by creating respective records in the feed.

System Integration Testing is not needed as this doesn’t have any downstream systems and the feeds from the upstream are validated in the System Integration testing of respective systems.

Testing Of Member Portal

Member Portal should be capable of the following:

  • View policy details and claim status.
  • Make change requests in policy details.
  • Make premium payments.

Positive flow System Testing should include scenarios to

  • Log in and view policy details and claim status.
  • Make change request to change address, name, phone number, etc.
  • Make premium payments.

Negative flow System Testing should include scenarios to

  • Log in with invalid credentials.
  • Make payment for a paid premium bill.
  • Make payment with an invalid check.

System Integration Testing is not needed as this doesn’t have any downstream systems and the feeds from the upstream systems are validated in the system integration testing of respective systems.

Testing Of Provider Portal

Provider Portal should be capable of the following:

  • View provider details, member details, and claim status.
  • Make change requests in provider details.

Positive flow System Testing should include scenarios to

  • Log in and view provider details, member details, and claim status.
  • Make change request to change address, name, phone number, etc.

Negative flow System Testing should include scenarios to

  • Login with invalid credentials
  • View member details with an invalid member ID

System integration testing is not needed as this doesn’t have any downstream systems and the feeds from the upstream system are validated in the system integration testing of respective systems.

Testing Of Broker Portal

Broker Portal should be capable of the following:

  • View broker details and commission payment.
  • Make change requests in broker details.

Positive flow System Testing should include scenarios to

  • Log in and view broker details and commission payment.
  • Make change request to change address, name, phone number, etc.

Negative flow System Testing should include scenarios to login with invalid credentials.

System Integration Testing is not needed as this doesn’t have any downstream systems and the feeds from the upstream are validated in the System Integration Testing of respective systems.

That’s it- that’s all the modules and the aspects we would test in them.

Important Tips For Testing Healthcare Software

Tip#1) Dates are important and have to be accurate because a slight change in the date may cause a major defect to be un-noticed.

Tip#2) In Healthcare, there are many test parameters such as different types of plan, members, providers, brokers, commission calculation method, etc., – so care should be taken while designing test cases by having a track of parameters covered and not covered.

Tip#3) Know the business users for the respective systems and think from their perspective to find any the best defects.

Tip#4) It is not needed to follow the same order for system testing and the scenarios provided here just cover the overall functionality of a healthcare application. You may also need to include some more scenarios (more hints at this post) based on the requirements you receive.

Tip#5) Health care is now moving towards a cost-effective way of providing care. Thus they have introduced an exchange model where the subscriber can have a view of plans given by all the insurers which increases the competitive nature of the insurers thereby indirectly stating the need for cost reduction.

As healthcare evolves, there will be a need for the change in software being used and there comes the revenue for IT by creation, modification, and testing of software applications involved- which means we can anticipate more projects in this domain. So, keep a lookout, if this interests you.

Tip#6) The key to success in health care application testing is claims – the complete knowledge of them and how they are adjudicated, etc.

Conclusion

Well, that covers the basics of the healthcare domain and a way to test healthcare applications.

As testers, we know nothing is defect free. This article may also have some defects, if you find any defect or have a question please leave a comment. We welcome your valuable feedback on the article, as it will drive us towards excellence and improvement.

Wish you all the very best for your future endeavors as a Healthcare tester. See you around!

Recommended Reading

54 thoughts on “Testing Healthcare Applications – Tips and Important Test Scenarios (Part 2)”

  1. Hi,
    The article is very helpful.
    I am very new in Healthcare domain, There are other Desktop applications in Healthcare like Interface (It connects legacy systems by using a standard messaging protocol. Because hospitals and other healthcare providers usually have different systems for different aspects of services, they are often unable to communicate with each other. interoperability platform to achieve Data flow between multiple Health care applications in the industry.)

    So my query is How to do performance testing on those desktop applications.

    Can you please share the articles related to HL7, HIPAA, DICOM etc for healthcare domain testing and mail id: trimukhesatish7@gmail.com

    Reply
  2. This is some interesting and limited information about some possible testing scenarios for a Health Insurance Claims Domain. It is missing at least 10 different systems and scenarios for an entire HealthCare Domain. Pharmacy, Pre-Cert, DICOM (Medical Imaging and Storage), Referring Provider Systems (EEMR, RIS, PACS, etc…), Coding, Financial Auditing, Health Care Auditing, Quality Reporting Measures, Dictation, and Monitoring are just a few things covered. Great Article but not as complete as stated for the Health Care Systems Domain. Somewhat complete for a Heath Insurance Billing Domain, but only if you leave out all the Audit, Data security, and Government Regulation systems.

    Reply
  3. Hi, Thats a nice article for begginers. Can you please give information on how a claim is loaded into FACETS application and what stages does it go through leading to final payments along with the testing scenarios.
    Emai id: abhigna515@gmail.com

    Reply
  4. Hi,
    It’s a nice for beginners on Health Care domain knowledge.

    Could you please write an article on Health Care EDI claims process…

    Thank you.

    Reply

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