HealthCare Domain Testing with Sample Test Cases

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HealthCare Domain Testing

Healthcare domain testing is a method of evaluating a healthcare application for criteria such as standards, safety, compliance, and cross-dependency with other organizations. The goal of healthcare domain testing is to assure the application's quality, dependability, performance, safety, and efficiency.

Knowledge of the Health Care Domain at a Basic Level

The single body that is a hospital or a provider weaves the entire healthcare system together (doctor).

Among the other entities are −

Insurance company: Medicare, Medicaid, BCBS, etc.
Patient/Consumers: Patient Enrolled
Regulatory Authority: HIPAA, OASIS assessment, and HCFA 1500, etc.
Health-care and Life-Science solution Vendors

The Basics of Health-Care Terminology

Provider − A health care professional (doctor), medical group, clinic, lab, hospital, or other entity licensed by health care services is referred to as a provider.

Claim − A claim is a request to your health insurance company to cover a medical expense.

Broker − An insurance broker is a person who negotiates and obtains insurance on behalf of an insured or potential insured.

Finance − Insurance companies that pay for medical expenses, either government-sponsored (Medicare or Medicaid) or privately-owned (BCBS)

Medicare − Medicare is a government health insurance program for adults over the age of 65 and those who are permanently disabled.

Medicaid − Medicaid is a federal-state partnership that helps low-income families and individuals cover the costs of medical care.

CPT code − A contemporary procedural terminology code is a set of medical codes that are used to define medical, surgical, and diagnostic procedures.

HIPAA − It is a system of rules and regulations that must be followed by doctors, hospitals, healthcare providers, and health plans in order to perform their services.

Business Processes in Healthcare

The majority of healthcare organizations have implemented software to ensure the system's smooth operation. For each entity dealing with this, this software solution provides all of the information in a single document

Connecting this entire system to a single web application is a significant undertaking, and getting it to operate properly is much more difficult. This health application must undergo extensive testing and must pass through several stages.

How to Test a Healthcare Application?

An Insurer requires different applications to manage the following −

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

In most cases, a healthcare application will include the following systems −

Member system − To keep track of policyholder information, as well as various plans and their benefits lists, and to create premium bills for policyholders based on their plans.
Provider system − to keep track of provider information
Broker system − To keep track of broker information and calculate commissions
Claims system − For submitting and validating claims
Finance system − To make the required payments to the supplier, member, or broker
Member Portal − View policyholder information, pay premiums, and submit a request for policyholder information changes.
Provider portal − To display provider information and submit a change request for provider information.
Broker portal − displays broker information and allows brokers to seek changes to their information.

Testing of Providers system

Sample Test Scenarios for providers (doctor/hospital) system −

S.NO	Test Scenario	Test Cases
1	Access to providers system	The provider system should allow us to enter, amend, and save data about the provider.
2	Positive flow System Testing	It has scenarios for entering several sorts of providers, changing their details, saving them, and inquiring about them.
3	Negative flow System Testing	Allows you to save incomplete provider information, contract effective dates, and facts about existing providers in the system.
4	System Integration Testing	Validate the feed to the member system, the finance system, the claim system, and the provider portal. Also Verify that the modifications made in the provider portal are reflected in the corresponding provider's record.
5	Positive flow providers portal testing	Log in to see information about providers, claim status, and members. Make a request to alter your name, address, phone number, or other information.
6	Negative flow providers portal testing	See the details of a member with an invalid ID Invalid credentials were used to login.
7	Positive flow Broker portal testing	Log in to see information about the broker and the commission payment. Submit a request to alter your name, address, phone number, or other information
8	Negative flow Broker portal testing	It should cover cases such as logging in using forged credentials.

Testing of Broker System

Sample Test Scenarios for Broker System −

Test Scenario	Test Cases
Broker System	It must be able to edit, enter, and save broker information. Calculation of broker commissions based on premium payment details from the member system
Positive Flow System Testing	For various sorts of brokers, enter, save, and amend their records. Calculate the commission for active brokers by producing a feed file with the proper data for members with different plans.
Negative flow System Testing	Fill in the blanks on a broker record and save it for different sorts of brokers. Calculate the commission for the terminated broker by making a feed file with the proper records for members with different plans. Calculate the commission for the invalid broker by making a feed file with the proper records for members with different plans.
System Testing	The feeds are validated by downstream systems such as the financial system, broker portal, and member system. Verify that the modifications made in the broker portal are reflected in the corresponding broker record.

Testing of Member System

Sample Test Scenarios for Member (Patient) System −

Test Scenario	Test Cases
Member system	Enroll, re-enroll, and dismiss a member. Remove the dependency and replace it with a new one. Make a premium bill. Process payments for premiums.
Positive Flow System Testing	Enroll different sorts of members based on the current, past, and future effective dates. Inquire about and replace members. Prepare a premium bill for an active member for the month ahead. Terminate an active member with a termination date greater than the effective date in the past, present, and future. Re-enroll a terminated member using his or her current, previous, and future effective dates. Reintroduce a defunct number
Negative flow System Testing	Enroll a member with inadequate data Prepare a premium bill for the following month for a terminated member.
System Integration Testing	verify the feed to downstream systems such the provider portal, the broker portal, the finance system, and the claim system. Verify that the changes made in the member portal have been implemented into the appropriate member record. Process the payment of a premium bill generated using a feed from the members portal, which includes payment details.

Testing of Claims System

Sample Test Scenarios for Claims System −

Test Scenarios	Test Cases
Claim System	Health-care claims should edit, enter, and process claims for both members and dependents. When inaccurate data is entered for invalid claims, it should throw errors.
Positive Flow System Testing	It should include the scenario of editing, entering, and processing claims for both members and dependents.
Negative Flow System Testing	It should validate and submit a claim with a procedure code and diagnosis code that are both invalid. Use the inactive provider ID to validate and enter a claim. Validate and enter a claim for a member who has been terminated.
System Integration	A scenario should be included to validate the feed to downstream systems such as provider and finance portals.

Testing of Claims System

Sample Test Scenarios for Claims System −

Test Scenarios	Test Cases
Claim System	Health-care claims should edit, enter, and process claims for both members and dependents. When inaccurate data is entered for invalid claims, it should throw errors.
Positive Flow System Testing	It should include the scenario of editing, entering, and processing claims for both members and dependents.
Negative Flow System Testing	It should validate and submit a claim with a procedure code and diagnosis code that are both invalid. Use the inactive provider ID to validate and enter a claim. Validate and enter a claim for a member who has been terminated.
System Integration	A scenario for validating the feed to downstream systems such as the provider and finance portal should be included.

Testing for regulatory compliance

Health regulatory bodies place a high focus on safeguarding patient sensitive data and health information. The testing should be carried out in accordance with the requirements of such regulatory authorities.

Sample Test Scenarios and Test cases for Regulatory Compliance −

Test Scenarios	Test Cases
User's Authentication	Using a verification mechanism to verify that only the correct users gain a login and to prevent others from doing so.
Information Disclosure	Access to information is granted based on the user's job and the patient's limitations.
Data Transfer	Points ensure that data is encrypted at all times.
Audit Trail	With a correct set of audit trail information, all transactions and attempts to access data are logged.
Sanity Testing related to regulatory body	Perform sanity checks and confirm that data encryption is in place in certain places such as EPHI (Electronic Protected Health Information)