The Client, the healthcare industry’s most comprehensive provider of cost management solutions, acts as an intermediary between its nearly 900,000 participating healthcare providers and, and its 1,400 clients providing claims re-pricing services at an estimated volume of over 40 million medical claims per year.
Business Needs and Objectives
The client was experiencing challenges in Electronic Data Interchange (EDI) testing, including verifying that EDI based healthcare claims records were transmitted and stored as required. Many of the claims being processed by the client use several different EDI formats, including X12 and NSF. The X12 formats used for EDI include 4010 and 5010. In some cases data is transmitted in an ASCII format which has a unique structure.
Tests must be executed to compare the segments, elements, and sub-elements in X12 files between the baseline file and the latest generated file. Test claims are inserted to facilitate data set comparisons. Test engineers analyze both inbound and outbound files and the resulting database entries. Both Positive and Negative tests are employed to thoroughly test the EDI application. End to End testing of both the GUI frontend and the API backend of EDI applications along with database verification testing is required.
Since EDI specifications are complex and extensive, manual testing is arduous and labor intensive. Testing a single workflow can take hours or even days if performed manually.
The client was looking to achieve an optimal level of test automation and increase test efficiency and effectiveness.
The QualiTest Solution
QualiTest’s test engineering professionals deliver comprehensive, advanced EDI testing services. To perform EDI testing in a more cost-effective and timely manner, QualiTest has created a test automation framework to specifically test EDI-based applications. This framework was developed into a suite of testing solutions customized for each client after extensive identification and development of an in-depth understanding of the client’s applications and system architecture. QualiTest’s engineers use this special EDI framework to thoroughly test its customers’ EDI based applications.
Some of the key functions performed during the EDI testing process include:
- Analyzing EDI records to efficiently identify variances at the file and database level
- Employing heuristic parsing algorithms to conduct the required file comparisons
- Managing large batches of claim data while eliminating application dependencies through a process for loading all types of claims directly to the database.
- Developing and generating a reporting mechanism to highlight EDI-related data comparisons and variances in the EDI file and the database.
- Cultivating flexibility by utilizing parameterization of input variables, allowing the tests to be quickly adaptable to changes and fluctuations
- Designing for scalability in tests so that additional claims or files could be added or removed with ease.
Some benefits that have resulted from QualiTest’s EDI testing services include:
- Efficiency improvement of up to 95%. Moderately complex EDI tests that would take an hour or more to conduct manually can be executed in 5 or 10 minutes. Even extreme tests that would take a day or more to complete manually can be run in under an hour.
- Advanced tools, metrics and techniques that are designed specifically for EDI allow stakeholders to track the statuses of projects
- Gaps and risks are identified early in the process, reducing bugs at later stages and avoiding project delays.
- Cost savings by utilizing a QualiTest-developed framework customized for the client’s requirements rather than a proprietary tool
- Calculated positive ROI gains within months after the start of a testing engagement
- The client received expedited test automation implementation as a fixed price service, resulting in lower prices.
- The client can now more effectively work with and control fresh claim data rather than relying on preexisting or manually loaded claims.