Physician Pathways Group

A unanimous law that cannot be used.

North Carolina created a license so experienced physicians trained abroad could help close the state’s severe physician shortage. A later statute, the Medical Board’s choices, and the state’s largest insurer have left it nearly unusable.

What the General Assembly passed

North Carolina’s internationally-trained physician employee (ITPE) license lets an experienced doctor trained abroad practice at a North Carolina hospital or rural medical practice without repeating U.S. residency, then apply for a full license after four years. The General Assembly created the license in 2023 and rewrote it in 2025 in House Bill 67 (Session Law 2025-37). That bill passed without a single “no” vote: 117–0 and 109–0 in the House, 46–0 in the Senate.

The need is real. Rural North Carolina counties have about 71 primary care physicians per 100,000 residents, compared with about 104 in urban counties.

Source: WWAMI Rural Health Research Center, University of Washington (October 2025).

The legislature also anticipated the obvious obstacle. The statute says an applicant may apply for the license before receiving federal work authorization, and simply may not begin working until that authorization arrives.

A later law closed the loop

Months later, the Regulatory Reform Act of 2025 (House Bill 926, Session Law 2025-94) required every occupational licensing board to verify each applicant’s Social Security number with the Social Security Administration. The Medical Board applies that requirement to every application received after May 21, 2026, ITPE applications included. For a physician abroad, the two laws together form a closed loop:

  1. The ITPE statute says the physician may apply before having U.S. work authorization.
  2. The license cannot be issued until the Board verifies a Social Security number.
  3. The physician cannot get a Social Security number without U.S. work authorization.
  4. The employer cannot obtain that work authorization without a license, or the state’s confirmation that one will be issued.

The permission in step one leads nowhere.

The federal government already solved this. The Medical Board won’t use the fix.

Federal immigration rules anticipate exactly this problem. Under 8 C.F.R. § 214.2(h)(4)(v)(C), a work visa can be approved for up to one year when a state license would otherwise be issued except for the applicant’s lack of a Social Security number or work authorization. What it requires is the licensing board’s confirmation that the application is otherwise complete.

Other state medical boards provide that confirmation. Massachusetts’s Board of Registration in Medicine, for example, issues a letter stating that the application is complete and the license will be issued once a Social Security number is confirmed.

The North Carolina Medical Board told us in September 2026 that it will not issue that letter. It will review the rest of an ITPE application while the Social Security number is pending. It will not say so in writing. Neither statute requires that refusal. It is a choice, and it effectively shuts out every internationally trained physician without existing U.S. work authorization — the very physicians the 2025 law expressly allowed to apply first.

Even with a license, the largest insurer won’t pay

Physicians who already hold U.S. work authorization can get the license. Then they run into insurance credentialing, which the statute does not address. What we found in October 2026:

  • Blue Cross NC told us it requires board certification to credential a physician, with no exceptions and no case-by-case review. Blue Cross covers nearly half of North Carolina’s commercially insured patients, far more than any competitor. ITPE physicians, by design, have not completed the U.S. residency that board certification usually requires. For most employers, a physician who cannot bill Blue Cross is a physician they cannot hire.
  • UnitedHealthcare would not give us an answer. Acceptance appears to depend on committee review of each physician.
  • NC Medicaid confirmed in writing that the ITPE license is recognized for enrollment and that board certification is not required.
  • Malpractice carriers we spoke with were open to the question but would not commit to terms.

Credentialing takes three to six months after the license, and the license takes roughly three months after a job offer. An employer can wait most of a year to put an ITPE physician to work, and then cannot bill the state’s largest commercial insurer for that physician’s care. Few employers can absorb that. Only practices that rely mainly on Medicaid can work around it. That is why we could not build a placement service on this pathway, and why few employers will try.

What would make the law work

  • Direct the Medical Board to confirm in writing, on request, when an ITPE application is complete except for a Social Security number, so the federal one-year exception can be used. Alternatively, let ITPE applicants complete review before Social Security verification, with verification required before the license issues.
  • Require health plans regulated by the state to credential ITPE-licensed physicians on the same terms as other licensed physicians in the same specialty, without requiring board certification.

Why this page exists

Physician Pathways Group worked to place internationally trained physicians through the ITPE pathway. We came close but never completed a placement, and in October 2026 we stopped trying because of the problems described above. This page stays up so they are on the record.

The ITPE pathway, in brief

For physicians, employers, and anyone trying to understand what the law allows.

Who it’s for
Physicians who graduated from medical school outside the United States, are licensed abroad, and have substantial clinical experience. No U.S. residency is required.
Exams
USMLE Steps 1 and 2, plus Step 3 or recognized board certification.
Training or practice
Either two years of postgraduate training approved by the country of licensure plus five years of independent practice, or ten years of practice in that country.
Job offer first
A full-time offer from a North Carolina hospital or a qualifying rural medical practice. Rural placements require a North Carolina–licensed physician practicing on site.
Scope
Practice is limited to the employer the license is tied to. Leaving that employer makes the license inactive.
After four years
Eligible to apply for a full, unrestricted North Carolina medical license.
Work authorization
Physicians may apply before receiving it but may not begin work until they have it. The license itself confers no immigration status.

Full requirements: G.S. 90-12.03 and the North Carolina Medical Board.

Questions about this page: info@pathwayimg.com