National Claims Processor Software and Market Access Services for the Pharmaceutical Industry

New York

American HealthCare Capital is pleased to introduce innovative software solutions and technology engineered to compete in the commercialization process that manufacturers of pharmaceutical products and medical devices engage in. This pharmacy claims processor software business represents a 3-tier total service and technology platform with Market Access Services and Solutions for Patient Service Program development, administration, execution, and delivery. The total service solution is supported by new, efficient, approved, patented technology that addresses the pharmaceutical industry’s most pressing needs and challenges.

Technology development began in 2018 and the organization launched in 2021, providing pharma (the payers) with market access services and solutions to pharma sponsored affordability programs. The process begins in Tier-1, which was created and led by a think-tank of devoted industry leaders with an in-depth understanding of market access strategy, claims processing, and reimbursement challenges for medical and pharmacy benefit coverage. Tier-1 provides solutions and mitigation strategies to pharma for retail and specialty drugs that address the changing climate of cost-sharing programs, compliance and budgetary management, warranty programs, CMS rulings, and PBM processing challenges such as accumulator and maximizer programs, and more.

Tier-2 is designed to execute and administer over Tier-1 solutions by providing leadership with the tools and cloud-based technology to target the right market, support patient engagement, and connect with pharmacies and non-pharmacy providers nationwide. Tier-2 helps pharma optimize their brand’s performance through a suite of program integrity services, including real-time execution of claims processing and reimbursement for all sites of care, real-time updates to program logistics, on-demand data and analytics, data aggregated reporting, and transparency.

Tier-3 represents non-commercial dispensing pharmacy services for member-based, manufacturer-sponsored, free drug programs such as Patient Assistance Programs (PAPs), and replacement product, starter, and bridge programs. Services provided include customer care support through pharmacy clinical services, member enrollment obstacle mitigation, adverse events reporting, and a program help desk. They are located and fully licensed in New York State in a 7,500 sq/ft facility with 2 additional mezzanine levels for additional storage.

Tiers 1, 2, and 3 can operate together as a total pharmacy claims processor solution or can be independently contracted based on the needs of the manufacturer or vendor. Revenues from their beta trials are under $1 million with pending contracts out for signature that can kick start the company into profitability. The Client profile can be one of two parties: 1) a manufacturer of pharmaceutical drugs, devices, diagnostics, or other clinical products, or 2) an industry vendor in need of a contractor that can provide white label services for a similar or customized business model.

There are three owners: two are pharmacists, and one is an entrepreneur experienced in finance and real estate. Additional staffing includes two C-level executives who lead IT and Product development, plus a help desk manager. Their technology partner has over 20 years of experience in healthcare and provides ongoing support for the technology. The tech team is a hybrid model based in the U.S. and overseas. They maintain the day-to-day tech operations, maintain the AZURE environment that the technology lives in, and manage all upgrades and enhancements.

The owners would be willing to stay on as employees for 1-2 years after a sale. Last TEV (Total Enterprise Value) was completed in early 2022 with a $65 million valuation from a certified third-party valuation company. Owners are seeking to sell a 10% – 100% ($6.5MM – $65MM) stake in the company, which includes the Tier-3 facility, and they would consider an earn out.

If you would like to learn more, please use the form on the right-hand side of the page to execute our NDA. You will need to copy the Listing Code and Listing Title from the summary above to complete the NDA.