A legal battle brewing over physician certification could reshape how doctors practice medicine in the United States. Since 2018, physicians have filed lawsuits challenging the American Board of Internal Medicine (ABIM), alleging its maintenance of certification (MOC) requirements create an unfair, costly system that effectively forces doctors to continually re-prove their competence.
A Landscape of Legal Challenges
The most prominent case, Association of American Physicians & Surgeons (AAPS) v. ABIM, claims the ABIM leverages its monopoly on initial certification to compel physicians into expensive and time-consuming recertification cycles, threatening their ability to practice if they don’t comply. A federal district court initially dismissed portions of the case in 2022, but the Fifth Circuit Court of Appeals revived key arguments in 2024, allowing the lawsuit to proceed.
At its core, the legal argument centers on whether the ABIM’s MOC requirements, tied to its initial certification monopoly, create an anticompetitive system. If successful, the case could redefine the certification landscape under antitrust law.
Real-World Impacts on Physicians
The impact of these disputes isn’t just theoretical. Consider Dr. Nguyen, a hospitalist who requires ABIM certification to maintain her hospital staff position and satisfy her malpractice insurer. When she questioned the value of MOC, her administrator emphasized that “certification is mandatory for hospital credentialing,” leaving her with little choice.
Meanwhile, Dr. Lawson, a cardiologist in private practice, decided to discontinue MOC after finding no clinical benefit. While he retained his original certification, the ABIM marked him as “not participating.” This led to scrutiny from his insurer, a reevaluation of his hospital privileges, and a “lapsed” certification status on the ABIM website.
Both physicians remain legally compliant, yet their livelihoods are constrained by a credential that is, in practice, far from voluntary.
The Argument Against Coercion
Plaintiffs argue that the ABIM’s control over certification has become so pervasive that MOC participation is no longer optional. They contend that hospitals, insurance companies, and payers often treat ABIM certification as a prerequisite for employment or credentialing.
This raises the legal issue of “tying,” an antitrust concept prohibiting companies from forcing customers to purchase one product to access another. In this case, the argument is that doctors must first purchase initial certification and then continually purchase MOC to maintain their ability to practice.
The ABIM maintains that MOC participation is voluntary, serving the public interest by ensuring ongoing competence, and that credentialing decisions are made by hospitals and insurers, not the board itself.
However, many physicians feel the line between voluntary and required has blurred. In today’s healthcare environment, “voluntary” certification often feels as essential as maintaining malpractice insurance.
Credentialing: A Systemic Issue
The conflict stems from the modern credentialing ecosystem—a complex network of requirements that amplify the power of MOC. Hospitals, insurers, and health systems increasingly use board certification as a proxy for quality, assuming that certified physicians have demonstrated competence and that maintaining certification signifies continued excellence.
However, this assumption lacks robust validation. No large-scale studies have definitively shown that hospitals requiring MOC achieve better patient outcomes than those that do not. Instead, a circular system has emerged: boards require maintenance, hospitals require board recognition, insurers require credentialing, and physicians must comply to avoid professional repercussions.
This creates a subtle but powerful form of coercion, with no single entity taking responsibility.
The Financial Burden of Compliance
One physician estimated the “MOC tax” at roughly $5,000 every five years, encompassing exam fees, travel expenses, continuing medical education (CME) purchases, and time away from practice. Extrapolating this across the more than 200,000 ABIM diplomates reveals a substantial financial impact. The board’s tax filings show tens of millions in annual revenue directly linked to MOC.
Critics suggest this structure incentivizes the continuation of burdensome requirements, regardless of proven benefit, and that MOC has become more about sustaining an administrative enterprise than promoting professional development.
Fragmented Oversight and Alternatives
The ABIM operates as one of 24 member boards under the American Board of Medical Specialties (ABMS). Each board sets its own standards, timelines, and fees. While the ABMS provides overarching principles, there’s no unified mechanism to evaluate whether these maintenance systems actually improve patient care.
Alternative certifying bodies, such as the National Board of Physicians and Surgeons (NBPAS), offer CME-based recertification without exams or point systems. Acceptance of NBPAS credentials varies among hospitals and insurers, creating what some call “credentialing by ZIP code”—where a physician’s recognition depends on location, not competence.
Reform: Legal and Professional Paths
Even if the lawsuits against the ABIM succeed, legal remedies alone may not resolve the underlying issues. Courts can address anticompetitive behavior, but they cannot legislate professional consensus or rebuild trust. True reform requires a collective decision within medicine regarding the meaning of continued certification and its alignment with measurable outcomes.
This means clearly defining the goals of these processes: ongoing competence, lifelong learning, or patient safety. The system must then demonstrate evidence for each objective, rather than simply assuming it.
An Uncertain Future
The legal battles continue, and the ABIM’s recent reforms, such as the 2024 elimination of the two-year point check-in, are seen by some as reactive measures designed to reduce friction rather than address the core monopoly concerns. The board continues to defend MOC as essential for public accountability and professional integrity.
However, skepticism among physicians remains strong. Many view the board’s changes as incremental responses to legal pressure and growing competition.
As one physician recently stated: “It’s not that we don’t believe in lifelong learning. We just don’t believe in paying for it twice.”
Moving Forward
Rebuilding trust requires more than eliminating redundant rules. It demands transparency regarding revenue allocation, evidence that the time and expense improve outcomes, and a reimagining of certification as a tool for learning, not a punitive measure.
A portable credentialing system integrating CME, specialty maintenance, and state licensure would be a positive step. Physicians should be able to demonstrate ongoing competence through metrics like peer-reviewed case evaluations, clinical performance benchmarks, or documented quality improvement projects, verified through a national database.
The courts may soon determine whether the ABIM’s structure crosses the legal line between quality assurance and market control. But even a favorable ruling won’t restore confidence until the system prioritizes learning and improvement over simply checking boxes and collecting fees.
Until then, physicians will continue to learn, improve, and care for patients, often despite the organizations that claim to represent them.
Brian Hudes is a gastroenterologist.
