An In-depth look into the Health Care Sector and Health Care App Testing:
In this piece, we will investigate information about the health care sector, its constituents, testing notions, and assessment methodologies.
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This series of articles is vital for those aspiring to delve into and embark on a new area of testing. It will guide you to comprehend the operation of health care programs and familiarize you with the testing procedures.
To sum up, this piece will function as an indispensable origin point and manual for your journey into health care awareness. The forthcoming part of this series will center on presenting testing scenarios for various applications within the Health Care sector.
To become proficient in testing, understanding the domain is a key element. Thus, we will now delve deeper into comprehending the client’s business operations.
An Overview of the Healthcare Sector
Healthcare or health insurance operates in a similar way to conventional insurance. In any insurance setting, the insurer (insurance company) proposes plans, and the consumer (subscriber or policyholder) acquires the preferred policy. The insurer obtains the premium amount from policyholders and rewards legitimate claims.
In the landscape of healthcare insurance, there are additional significant contributors such as providers, TPAs (Third Party Administrators), brokers, and so on.
A closer examination of these principal contributors gives the following observations:
#1) Insurer: An organization that devises plans, offers policies, and reimburses policyholders or providers for rightful claims.
#2) Policy Holder: A person or organization that procures policies from insurers or brokers, remits premiums to insurers, and may submit claims.
#3) Provider: A person or organization that offers healthcare services to policyholders and their dependents. They either get paid directly from policyholders or submit claims to the insurer for compensation.
#4) TPA: An individual or entity that manages claims for the policyholder or provider and obtains payment from the contributing party for claim management.
#5) Broker: Brokers operate as agents who sell policies on behalf of insurers to customers and receive commissions in return.
To illustrate, consider the subsequent scenario to comprehend the roles of disparate contributors:
Mr. Enosh procured a healthcare policy that covers general physician consultation and vision issues from Mr. Ponnar. He remitted the premium amount to a healthcare company.
When Mr. Enosh fell sick, he sought treatment from the physician, Mr. Sabari. Post consultation, Mr. Sabari provided him a prescription, and Mr. Enosh filed a claim to the HealthCorp Company for compensation. HealthCorp Company paid a commission to Mr. Ponnar for Mr. Enosh’s premium payment.
In this example, ‘General Physician Consultation’ and ‘Vision Problems’ are the perks 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 understand the difference between a policy and a plan, we can think of a plan as a type and a policy as an object (an instance of the type). A policy can be classified as an individual policy or a group policy, depending on whom it covers.
Individual Policy: In this case, one person is the policyholder, and both the individual and their dependents enjoy the perks of the health plan. The premium is paid by the individual.
Group Policy: In this scenario, an organization (typically an employer) is the policyholder, and the members (employees) of the entity and their dependents can enjoy the benefits of the health plan. The premium is paid by the organization.
For instance, to better comprehend a group policy, consider the following example:
MotoCorp Company acquires a policy from HealthCorp Company to provide health insurance coverage for its employees and their families. The claims are managed by EasyClaim Company. In this case, MotoCorp Company is the policyholder, HealthCorp Company is the insurer, and EasyClaim Company is the TPA.
Strategies for Testing a Healthcare Program
Before testing a healthcare app, it’s crucial to acquaint oneself with the workflow of the healthcare sector. The earlier portion has introduced us to managed health care, and further details can be found here.
An insurer requires different programs to manage the following:
- Provider-related data
- Member data
- Premium billing/payment
- Broker data
- Entry/validation of claims
- Calculation/payment of broker commission
A healthcare program typically comprises the following systems:
- Member system: This system is used to maintain policyholder data, different plans and their respective perks, and to produce premium bills based on the plans of the policyholders.
- Provider system: This system is employed to manage provider-associated data.
- Broker system: This system maintains broker data and calculates commissions.
- Claims system: This system is tasked with entry and validation of claims.
- Finance system: Payments to providers, members, and brokers are processed through this system.
- Member portal: This is an access point for policyholders for viewing their policy-related information, making premium payments, and requesting changes in information.
- Provider portal: This is a portal for healthcare providers for accessing provider information and requesting changes in information.
- Broker portal: This is a portal for brokers to access broker information and request changes in information.
This might not be a thorough list, but it provides a substantial understanding of the systems involved. In addition, not all programs may be necessary in every instance. At times, individual systems are merged to form integrated programs, or maintained separately.
For instance, in some healthcare programs, the Provider system could be combined with the Member system. The term ‘healthcare program’ refers to a collection of systems managed by an insurer to facilitate their customers and partners.
Workflow for Testing a Healthcare Program
Healthcare programs feature an exclusive testing workflow that should be pursued in a particular sequence:
- For a member/policyholder to be registered in a health plan, a provider (Primary Care Physician) or a provider network has to be assigned. Therefore, there should be a mechanism in the member system to validate the assigned provider. This can be facilitated by a connection between the member system and the provider system, or periodic data feeds transmitted from the provider system to the member system. Thus, the provider system ought to be tested and ready for use before the member system is tested.
- A claim needs to include both the provider ID and member ID, along with other specifics. The claims system should validate the member and provider details to verify the claim’s correctness. Thus, the member and provider systems should be tested and ready for use before testing the claims system.
- The finance system requires information from member, provider, claim, and broker systems to process payments, issue checks, or make electronic funds transfers to the respective individuals or organizations.
- Provider and broker systems are standalone entities and can be tested independently.
- Portals should be tested towards the end of the testing procedure, as they depend on data from other programs.
At this point, you should have a clear comprehension of the sequence in which the systems in a healthcare program should be tested.
What’s Next?
The details provided above should give you the impetus to progress to the subsequent part of this series – “How to Test Healthcare Programs.” The forthcoming part of this article will concentrate on testing strategies and important testing scenarios.
About the Author: This guest post was penned by Vairavan R M, a seasoned professional in testing Health Care Programs and directing a team in a multinational company.
In the meantime, if you have inquiries, feedback, or need additional guidance in understanding the Health Care sector, do not hesitate to contact us. Keep an eye out for the next piece in this series.