For decades, physician board certification has typically involved certifying through one of the 24 specialty boards under the American Board of Medical Specialties (ABMS). 

But in 2022, an alternative certification pathway through the National Board of Physicians and Surgeons (NBPAS) was formally recognized by The Joint Commission (TJC), clearing the way for hospitals to use it in credentialing. NBPAS now represents more than 15,000 physicians and is accepted by about 250 organizations nationwide, including hospitals, health systems, and insurers.

The new option highlights emerging competition in physician credentialing — a system historically shaped by a small number of boards — as well as long-standing concerns among physicians about the cost and time required to maintain board certification.

Founded in 2015, NBPAS has marketed itself as a lower-cost, more clinically relevant alternative to ABMS-affiliated maintenance of certification (MOC) programs.

A 2025 analysis in The American Journal of Medicine, drawing on ABMS data, estimated that physicians collectively spend more than $12 billion on MOC fees and related costs throughout their careers.

Rather than requiring exams or ongoing assessments used by ABMS member boards, the NBPAS model relies on continuing medical education (CME). But the extent to which NBPAS’ expansion has influenced changes to MOC practices remains unclear.

For example, the American Board of Internal Medicine (ABIM), the largest of the ABMS member boards with nearly 300,000 physicians, has rolled out a series of updates to its certification model over the past several years.

A ‘Grassroots’ Alternative

Under the NBPAS model, physicians must hold an active, unrestricted license, have previously completed certification through an ABMS or American Osteopathic Association member board, and complete at least 50 hours of accredited CME every 2 years. NBPAS offers both general and subspecialty certifications across dozens of fields, including dermatology, internal medicine, neurology, obstetrics and gynecology, pathology, and radiology. The cost is $189 per certificate for a 2-year cycle.

Paul Teirstein, MD, president of NBPAS and chief of cardiology at Scripps Clinic, La Jolla, California, told Medscape Medical News that the CME-based model is designed to reflect a more collaborative learning experience. By contrast, typical certification exams are “done in isolation, under time pressure, without the ability to look things up or consult colleagues,” he said. “That’s not how medicine is practiced.”

While lower certification costs are attractive, Teirstein said many physicians fret more about the time burden, citing the cumulative demands of clinical care, documentation, prior authorization requirements , and other administrative tasks.

“The cost is just annoying,” he said. “The time is the part that everybody really objects to.”

He said the organization’s “grassroots movement” has seen steady growth, as it has worked to gain recognition from regulatory bodies and address barriers to adoption. As a nonprofit, much of its outreach has focused on education, including CME meetings, physician networks, and engagement with professional societies.

Still, adoption varies by institution. Although TJC recognized NBPAS as a “Designated Equivalent Source Agency,” individual health systems ultimately decide — through their bylaws and credentialing policies — whether to accept it in place of certification through an ABMS member board.

Teirstein said those decisions can depend on the composition of a hospital’s medical executive committee.

“You have to get the committee to support it, and it depends on who’s on it,” he said. “If someone has a stake in ABMS or has written test questions for them, they’re more likely to support that system.”

A System Resistant to Competition?

Breaking into established certification systems can be difficult.

“Markets tend to coalesce around singular certifications,” said Barak Richman, PhD, JD, professor of business law and co-director of the health law and policy program at the George Washington University Law School, Washington, DC.

He told Medscape Medical News that such systems are sometimes reinforced “simply because the profession benefits from monopolistic control,” or due to state regulation.

“It is hard to create and sustain a new, alternative professional certification system, even when markets would clearly benefit from one’s emergence,” he said.

Different state regulations add complexity. Teirstein said some states, like Texas, also have rules restricting which physicians can advertise themselves as “board-certified,” reserving that designation only for those certified by ABMS member boards.

A proposal at the Texas Medical Association’s 2025 House of Delegates meeting aimed to revise that rule to allow NBPAS-certified physicians to use the term, but the measure did not pass, according to NBPAS documents.

As a result of these legal and institutional constraints, Teirstein said some physicians maintain certification through traditional boards in addition to NBPAS.

NBPAS has lobbied lawmakers on these constraints and what it describes as “entrenched monopolistic practices” in the ABMS certification process that hinder competition and limit physician autonomy.

The issue has also been challenged in court by others. In a 2018 class-action antitrust lawsuit , physicians alleged that ABIM illegally tied initial certification to ongoing maintenance requirements, creating a monopoly that prevented competitors from offering lower-cost, less burdensome alternatives.

ABIM Defends, Refines Its Model

ABIM has updated its certification model in recent years, including changes aimed at improving flexibility for physicians. The group launched the Longitudinal Knowledge Assessment (LKA) in 2022, which allows physicians to answer online questions rather than take the traditional exam every 10 years at a test center.

Nadia Sirdar, MD, MPH, internal medicine physician and founder of Bethesda Modern Primary Care, Bethesda, Maryland, told Medscape Medical News that ABIM’s certification process can be “onerous and expensive,” particularly the $700 in-person exam fee. Maintenance fees run $220 for the first certificate and $120 for each additional one.

She has taken advantage of the newer LKA option and, along with the ability to earn CME credit by researching topics on UpToDate, she feels the current requirements are now “much more doable.” She’ll continue to maintain the certification because, in her view, there’s “not a choice — you can’t practice medicine without it.”

Still, she said alternative certification pathways could be beneficial if quality standards are maintained.

ABIM said in a statement that more than 92,000 physicians are enrolled in LKA, and participants spend about an hour per quarter completing assessments before receiving references and rationales that support learning.

“Patients expect their physicians to stay current,” the group said, adding that ongoing assessments like LKA provide a way to demonstrate that physicians’ knowledge remains up to date.

ABIM said the LKA option was developed with physician feedback and has received strong satisfaction ratings. In one study , 95% of participating physicians reported learning from the assessment, and more than 70% said it led to changes or intended changes in patient care.

ABIM certification maintenance fees run $220 for the first certificate and $120 for each additional one. Physicians who opt for the 10-year exam must pay a test center fee of $700.

The organization has also introduced a needs-based fee assistance pilot for physicians pursuing initial certification in internal medicine. The program is intended to offset the financial burden for physicians whose training programs or institutions do not cover certification exam fees, the group said. After receiving “exceptionally positive feedback” from early participants, ABIM said it will continue the pilot in 2026 and explore ways to expand it, such as potentially offering a similar option to physicians certifying in subspecialty fellowships.

ABIM said it has not seen a shift away from its certification, noting that very few physicians allow their certification to lapse.

In a statement to Medscape Medical News, ABMS said it views “independent, objective assessment” as a core component of certification, and that because “CME is self-directed,” it provides “no way of knowing whether physicians are remaining current with the knowledge and skills needed to care for patients.” In the past, the group has said that claims that NBPAS certification is equivalent to its member boards’ certifications are “misleading.”

Despite its growth, Teirstein said NBPAS continues to face structural and legal constraints. “But we’re here for the long haul,” he added.

Other specialty groups have also begun exploring alternatives. The move to establish a new certifying body for cardiology — the American Board of Cardiovascular Medicine — has drawn support from major professional societies, but ABMS declined the group’s 2025 application to become an independent board. ABIM remains the sole recognized certifying body for cardiovascular medicine.

Steph Weber is an award-winning freelance journalist specializing in healthcare and law.