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 understand and enter into the healthcare domain for testing, learn and understand health care application workflow and testing process.
In short, this article will be your first step and your initial guide to your healthcare knowledge quest. In part 2 we will provide test scenarios for different applications in the Healthcare domain.
To really excel in healthcare testing, healthcare domain knowledge is the key.
But, first, we need to learn the client’s business flow.
Health care domain- an introduction
Health Care or Health Insurance is similar to general insurance. As you know, in any insurance, an insurer will provide the plans and customer (Subscriber or Policy holder) will choose a policy of his desired plan. An insurer will receive the premium amount from the policy holders and the policy Holders will get reimbursements from insurer for the valid claims or Explanation of Benefits of what the insurer has paid. The same happens in healthcare insurance but in addition to insurer and policy holder there are may be other major contributors such as provider, TPA (Third Party Administrator), broker, etc.
We will now see each of the major contributors in detail:
An entity which creates plan, sell policy and reimburses policy holder or provider for the submitted valid claims.
- 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.
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. This may or may not be relevant, as many policy holders are purchasing healthcare insurance directly.
A person or an entity that manages the claims of policy holder or provider and receives payment for the management from the respective contributor.
- Broker: (if applicable)
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.
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.
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.
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.
How to test health care applications?
Before testing an application, we should be aware of healthcare industry work flow. The above information gives an introduction to managed health care, more details are available here.
An Insurer requires many applications to manage the following:
- Provider data
- Member data
- Premium billing/payment
- Claims entry/validation
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
- 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 – (if applicable) to display broker information and raise request for change information for brokers
This might not be the entire list of applicable applications. 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 systems. Healthcare systems are a set of systems maintained by insurers to facilitate information and payments from their customers and/or partners.
Health Care Application Testing Work flow
Healthcare systems are unique in that these applications should be tested in a specific order. The specific workflow of healthcare systems dictates the process:
- To be enrolled in a health plan a member must be assigned to a provider (Primary Care Physician) or a provider network,
- There should be a way for member system to validate the assigned provider.
- The member system must connects to the provider system or a data feed should periodically be sent to member system from provider system.
- The 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.
- Both member and provider system should be tested and ready to use before testing claims system.
- Finance system needs to have data from member, provider, claim to write checks or make EFT payments to the respective person or entity.
- Provider and broker (if applicable) systems are stand alone.
- Portals should be tested often (a schedule should be set) since it pulls data from many of the other applications.
Now, that’s the order in which the systems in healthcare application should be tested.
The above mentioned information is just the prerequisite for the next article: that gives a detail as to the “how to test” portion of Testing Healthcare Applications.
There are probably many schools of thought for this process. The important part of making your healthcare systems applications work properly, at the performance levels they need to be, is to have a testing strategy in place and to adhere to this process. The actual Testing process will be dealt with in the next 2nd part of this article.