PegaWorld 2026: Modernizing Veteran Family Member Programs: Better supporting Veterans and their families

All right. Good afternoon everyone. Thanks for coming to listen to me talk about what we do at the VA with Pega. I appreciate you all being here. So I work for the Department of Veteran Affairs, where it is our mission to support not just the veterans, but their orphans and their widows, which was the promise originally made by President Lincoln during his inaugural address in 1865. So that's been our ongoing mission. My program for the Veteran Family Member program supports the families of veterans, their spouses and dependents. We have five federally mandated programs. We do Champva. We do Spina Bifida CWVV, which is the children of the women of Vietnam. Camp LeJeune and the Foreign Medical Program. I've been with the VA for 18 years. I started out as a voucher examiner, processing claims for the medical program and have moved my way up through management into the program analyst role, where I first started to get to work on improvements through modernization.

And I now have the great privilege of leading our team that does Oint major project development within the veteran family member programs. We have been dedicated for the past 4 to 5 years on a mission of modernization, and one of the things we learned about this is that modernization is a process. It's not an end goal. You are never done modernizing. By the time you think you've got where you thought you wanted to be, there's another step to take. There's another hill to climb. And so embracing this as a process, which we need to focus on, our people can help us generate valuable outcomes, not just for the veterans and their families, but also for our employees as well and across the organization. So why does the VA need to modernize? We need to modernize because we have more people to serve every year. We have important and valuable people who are our customers.

We support veterans and their families at the VA. We consider taking care of the veterans families. Our mission, as well as taking care of the veteran, taking care of their families, allows veterans to focus on their health and recovery. They don't have to worry about their children and their spouses when they're sick, and so they can be healthy and whole. So those are two very important missions or why we drive IT modernization. Also, we want to empower our workforce. We have a very dedicated, loyal, hardworking workforce. Our employees work hard to deliver a mission they are passionate about. And so empowering them to do that better and easier and more effectively is really important to us. So in order to achieve our goals of better serving these growing communities of families and our dedicated staff, so we are working to get to these goals through system automation of our heavy workflows, connecting all of our systems and data that is seamless for our users, and it delivers the information they need when they need it to make accurate and timely decisions.

And we need to be able to manage and oversee the massive amount of data needed to make eligibility determinations, manage claim processing for beneficiaries so we can improve oversight of our programs and better manage government funds. So with this modernization of a process, instead of focusing on a goal, we really focused on the people to generate these outcomes for everybody. And so we do that by focusing on a process. We have been able to work and focus on our process and work towards moving up our staff up this ladder. The extraction of data, consolidated work into a single location has been critical to that work. So in 2023 and 2024, we started laying the foundations to keep climbing this ladder to get staff closer to the real work of serving benches and away from repetitive and manual tasks. We built digitized workflows, developed online capabilities, and organized work to create a stable environment for our staff so that they could focus on decisions.

And we wanted to slowly move away from our staff having to manually work things, make calculations, make decisions, move around, and we've moved them up from opening and sorting mail to triage work to making decisions quickly and allowing us to focus more on analysis and program management, which helps us provide more positive outcomes for our families and our employees. Modernization isn't just technology. It is transformation of processes, processes, and refocusing on what our job is, which is positioning VFMP to deliver faster, smarter and more transparent benefits to our veterans and families. So last time I was here, we talked about how we were digitizing mail to get away from a bottleneck and using dynamic workflows to help us modernize. And while that was happening, CHAMPVA was also experiencing exponential growth. The increase went up 23% between 2024 and 2025, which comes with an increase of applications and claims work.

The causes of this growth were the Pact act, which increased veterans 100% permanent and total population and increased family member eligibility. And at the same time, the VHA increased CHAMPVA communication and communication and engagement and online access. Also, getting our applications online just opened the floodgate for families who were finally given an easy access point to the program after years of trying to find it. The modernization and data extraction empowered us to tackle this growth in 2025 with our foundational work in doc MP. We were able to pull in modernization solutions and overcome a backlog that seemed insurmountable, with staffing limitations and mounting pressure of a new administration. A year ago, we hit the largest backlog in VFMP history, the largest backlog in VFMP history, and face headwinds of losing staff and incoming volume of just around 5000 applications a week. I'm messing up the slides, aren't I? 5000 applications a week.

Don't give me a clicker next time. So just around 5000 applications a week. We were six months out from the largest migration of eligibility in the history of our program, moving from our legacy system into an enterprise V, a eligibility solution. So we had this huge problem we were trying to tackle, and we had not a lot of time to do it. We had to get our inventory down. We had to get it under control. And so by leveraging what we'd already built with some of the new capabilities, not toast guys. I'm winning this one. All right. Leveraging these Pega workflows, OCR tools, and automation in our legacy system, we were able to bring the hard work of our staff and the modernization tools to go from a historical backlog of over 70,000 pending applications to less than 1000 working claims within days. Oh, sorry.

Within then to 1000 and working those claims within days rather than months, we were able to automate 77% of our application backlog, enrolling over 18,000 beneficiaries to our programs. CHAMPVA reached a benchmark of 1 million total active eligible beneficiaries by the end of 2025, and we were able to replicate this to our new eligibility system so that we did not lose the advantages we gained doing this work. When with this incredible work, we have been able to maintain staying under a week out on applications for eligibility to our program Since the beginning of this year, we also were able to. I got it. We also reduced the number of pending OHI certifications from beneficiaries. Through this automation process, we were allowed to. We were able to duplicate it. Processing 89% of the outstanding OHI certifications. The automation was able to work 131,000 of these certifications, and with the hard work of our staff, we were able to complete a total of over 226,000 certificates for our beneficiaries by the end of 2025.

These critical forms ensure beneficiaries records are maintained and that they have steady access to care throughout the changes of life. It was really important to get that backlog out of the way so that our beneficiaries could get reimbursed for their medical care. All right, so what did we learn through this process? So the first thing we learned is that oint business have to be in communication constantly. We have to be aligned in what our goals are so that we can achieve them. We have at the VFMP, an incredible tool that was built in-house by our strategic planner that is called. We refer to it as our roadmap tool, and we have our Oint partners. I have my frontline business partners, and I have my project team all connected in one place where anybody can input suggestions on initiatives and plans and tools that they want to see implemented.

And then we can take these things to leadership and get clear direction on the priorities of work. This has been an incredible boon to keeping our multitude of modernization projects outside of just Pega. We have about 60 current modernization efforts across our programs, and keeping all of those aligned and ensuring that our deadlines and our milestones meet has been critical. Also managing our tech debt. We, like every organization, have a massive amount of tech debt and making sure that we leave room for that as we are striving for our achievement, like our major goals, has been really critical and incredibly difficult. Getting staff buy in is also something we don't talk enough about. If you want your projects, if you want your technology to be any good, if you want to provide value to the teams that you're building for, if you don't work hard for that customer buy in, if you don't work hard for that change management, you're going to deliver a product.

And it doesn't matter how good it is, your staff are going to hate it and you're going to get blowback. So we've learned that constant improvement is hard and it's important to change management early to do change management early, not change management and constantly messaging to all levels. You have to get staff tools so they can engage effectively. So we have the roadmap, we have town halls, we do elaborations, and we do demos weekly to make sure that everybody knows what we're building and why we're building it and how we're going to get there. We also have done blueprint workshops. We've been encouraging the teams to learn how to use blueprint so they can go in, put in their ideas, get ideas of what it might look like, and talk to their developers about what they want to see in the tools. We're also working on doing a competition with our staff to have them have the opportunity to get into Blueprint and compete for that award of the best Blueprint, and then we're going to be able to implement it into our system so they can see that what they built and their ideas can happen in the real world.

Also, we've been working hard to utilize what we already have instead of leaning to the habit that we have to constantly build new things. We've been learning where to draw lines between what's a new workflow versus maybe just an old workflow that needs to be modified, or figuring out how to expand a process, pull something in and combine to make things more efficient. Examples of this are connecting our eligibility team to the OHI team. Eligibility comes in with the information the OHI team needs. It's a complete and smooth transition from one workflow to the next. We didn't have to build a new one. It's just a continuation thereof. It's also about pulling in integrations instead of building a new workflow, bringing the data in to what's already there. And then we're working on that for our appeals and our nurses, where we're bringing in multiple documents into a single place instead of having to have them bounce from the different areas.

So this is the VFMP roadmap through 2028. And we have a very ambitious future vision looking to predetermine nations, improving our compliance, being proactive and personal in our communications, and also looking to be more resilient and adaptive. How will we get there? You guys might want to ask, and I'll tell you, the things we're looking to do is leverage our tools, those we already have in our toolbox with a AWS Cloud enterprise data systems or Pega workflows. And on and on and on. And we're going to combine all of these different things. We're bringing all of the strings together to empower AI, machine learning and optimize what we have built, and we will do this through adding more friends, including other integrations, connecting with people not just within the VA, but beyond. Because in the VA, we're not making a decision just based on the information we have.

DoD is important to what we're doing. Medicare is important to what we're doing, the private health industry. And so looking to make friends and direct connections so that we can sync our data and stay in step with everyone else to ensure accurate and timely decisioning is really important. We will expand these tools to serve the VFMP programs. So not just CHAMPVA, who is the primary one we worked on this year, and not just claims and eligibility, but we're going to empower our nurses. We're working to expand the capability for the appeals team, for our foreign medical program, for our specialty programs. Through a many to one relationship, utilizing also smart claims to embrace automation and strive towards an industry standard utilizing X12 and EDI transactions, the care benefit coordination work where we will be able to see the holistic experience of our beneficiaries. And instead of just a single unique interaction, we are hoping to give care to our bennys in a white glove experience that for them is seamless from beginning to end.

Thanks guys. So what have you seen like some of your major roadblocks in implementing some of this? I saw the growth plan that you got from 2025 on. Is it more users or more internal, some of your roadblocks implementing this plan? How are we overcoming that growing volume? Yeah. Well, I mean, that's sort of the goal of and what we achieved in 2025. What we did is we were able to use the metadata that we had scraped off of these documents, and we used Pega to generate these outbound files so that we could automate processes instead of the manual process. Historically, in VFMP paper, submissions came in and our staff were manually typing them into and then swivel chairing to pull data. And so with the modernization that we pulled in, we were able to pull data and extract it and combined it into files and like a Json file and send it to our eligibility processing system that could then ingest that data and establish a file in a record.

And so that automation is really what allowed us to overcome that. We're still seeing that high level of volume, but with that built in automation, we now can maintain that volume at its current rate in about a week. So we're staying under about a week out on our applications through that automation process in claims, because we've now hit over a million beneficiaries and it continues to grow our claim volumes. What's climbing right now? And that's where we're hoping to leverage smart claims. So with smart claims, we're looking to extract through OCR and through online submissions the claim data necessary to generate an 837, which allows us to send that downstream to whatever claims processing system any, any one of our programs might use and automate that claims processing system. Instead of having to go in and manually type all that data to process a claim for payment.

What has been the impact on the employees specifically, like the numbers of employees? Has there been any kind of a reduction in the workforce because of this automation or need for retraining or anything like that? Definitely training. Um, you know, Pega was a new platform for us two years ago and we had to train staff how to get in there and get familiar with it. Now that they've been in there longer, they're pretty familiar. But every time we roll out a new, you know, that's that change management piece. You've always got to be up training and upskilling your staff, giving them the opportunity to learn new things. But, um, staffing has been an interesting conversation in the VA, right? Like we had a significant drop in staff and I'm kind of at a place where I'm not concerned about losing staff that the automation is getting in the way.

That stair step that I showed, and I probably was stumbling over my words, so it wasn't very clear. Um, that's really what I'm talking about is like, we're not looking at staff reductions so much as being able to move staff up from the processes they were doing. We were spending so much time sorting paper, we couldn't do a lot of analytics, right. We were spending so much time sorting paper, we couldn't spend a long time triaging, and our claims processors were having to do the triage work. And so being able to move people up those steps instead of saying, we can't use you anymore, getting that work and moving people up allows us to get to where we're now, doing more program management than we ever were able to do before more oversight, more fraud, waste and abuse. And so we're just upskilling people to those more important functions and letting the computers do the very basic redundant tasks that we're taking up our time before.

If you could go back and. You were starting the modernization project for the first time again, what's the one thing you would tell yourself to do that you think really helped make the project a success? From. So I sit at the juncture between business and I.t. Um, I'm not IT. I'm not a developer. I come from the business world, but I've learned a lot about tech over the years. And the one thing I see over and over again is that there are these incredibly powerful tools. And if you are a technical developer, if you work in Oint. Listen to me. Your best friend needs to be the business. They have to be in the room with you. They have to be talking to you, they have to see you, and they have to feel like you care and that you're listening. Because if they don't, it doesn't matter how beautiful the system is, you develop, they're going to reject it.

There's going to be pushback. There's going to be all this struggle that's unnecessary. And so my biggest regret in my Pega project is that when we saw what we could accomplish, there was a lot of excitement and we were like, let's go. And we didn't always bring our staff along for the whole ride. Instead, we built a roller coaster and we're like, here you go, get on it. Have fun. And you know, that idea that like, what we build is going to be loved is like just human nature. We put a ton of energy into something. We build something we know it's really cool. And then we don't understand when people don't think it's cool to change. Management is hands down to me. The biggest lesson I've learned is because if without it, it doesn't matter what work you do, how good the work is you do, or what you deliver.

And so really, I cannot stress that enough. That relationship between oint and business is the thing that I would have put more into at the beginning. Of this question. Hey there Eric. Excuse me. Hey there. Eric Herd with Accenture Federal. I'm a solution architect and also happened to be a veteran. So thank you for everything you do in your presentation. You talked about, you know, integrations and automation, focusing on that. Are you finding that the data you're receiving from your integrations is structured in a way where you can achieve automation, or is it still unstructured, unstandardized or freeform in a way that you need to apply a layer of human judgment before you apply the automation? Yeah, I think that's a good question that I, I think. There's a yes and right. Yes. With a lot of the initial intake, yes, we have been able to extract that and put it into a format that doesn't really require a human to touch, except for where we have very clear OCR low, no confidence scores.

And then we might step in and have a team do that verification work. But for the most part, what we see is that we are able to take the data as it's coming in, but it's a structured form. Like we have a structured form, we scan it. It's very easy to extract that data, put it into a format and stick it down the system. Right. Um, in other areas as we're doing these integrations. No. Right. Like, um, six months ago, we got into the eligibility enterprise for VA. It's called the Vas and it's the VHA eligibility system. And the reason we had to do all that work to burn down all that backlog is because we knew we were going to get into a new system. And things always slow down when you're training new staff and getting into something like this, and synchronizing and getting that data to line up has been my life's work for the past six months.

And so sometimes like that front end work though, is where it's at. Because now that we're getting that sorted out, then I can trust what the outputs are. And so I don't need that person in there. It's just taking the time to figure out how to make those legacy systems data line up and make sense. And then we're able to still automate the simple stuff. We still have to have our staff step in in the eligibility system we auto ingest in there, and then that creates the record. We still need a human in there making that final decision because there's so much nuance to those rules. We haven't been able to automate it. We're moving towards having the system be able to recognize, oh, this is a very simple case. It's very clearly two parents, two kids, none of the crazy exceptions, because at the front, it seems like we have a really easy decisioning process, but there's a cloud of what ifs and maybes.

And just in case this person, you know, and so but identifying those very easy, basic, straightforward cases are the ones we're working on right now to automate and get those out of the way so that our staff can pay attention to those more complex and nuanced choices. Thank you. Yeah. What are you most excited about for the next 12 months? I'm really excited for Tony Campbell to make smart claims fly. I'm really excited for the smart claims work. We are bringing in automation capability across the board, but this one will be really huge claims processing. We process billions of claims a year and we use all of these cool claims processing systems. Currently, we're in three different claims processing systems. We're getting into another. And so this idea that our claims processing systems are always going to change because modernization is a process, not a goal.

And so we know every so often we're going to have to change. And so smart claims, what it does is it delivers us an interface where our staff can stay focused. They can get all the data they need for the claim, they can review it. They can ensure that the data is correct. They can put everything together in a package, and then it spits out an 837 industry standard, and I can send that to any claims processing system out there, because there is no claims processing system that doesn't take an 837. And so getting into that process, my staff don't have to move. My staff are in smart claims. They know how it works. They're familiar with it. And when I switch from one system to the next system to the next system to the next, it won't matter. It won't change. So they'll be where they're comfortable, they'll be home, and they won't have to worry about what new system is Katrina forcing me to deal with.

Any other questions? All right. Well thank you Katrina. Appreciate it. Thank you guys.