Working as a zzp healthcare provider

You are a nurse, caregiver, maternity nurse, or other type of independent contractor working in the healthcare industry. As a professional, you are very aware of the fact that you are bound by laws and regulations. You work with people, which means quality comes first. What are some of the issues to keep in mind, and with what laws and rules are you required to comply?

If you plan to offer your services as an independent contractor (zzp’er, zelfstandige zonder personeel) in the healthcare sector, you can follow this roadmap to make sure you do not overlook anything. If you have already started, you should first check whether you comply with the laws and regulations for the healthcare industry, and whether being certified offers you any advantages. And how do you find clients? 

Growing market 

The number of independent contractors operating in the healthcare industry has increased by nearly 50% over the past five years. In 2022, almost 169,000 independent contractors were employed in the Dutch healthcare sector. The online platform zzp-erindezorg (in Dutch) reports that this is mainly the result of poor employment practices, a lack of appreciation for the work, and high workloads. 

Laws and regulations 

Independent healthcare professionals must, as independent healthcare providers, comply with specific laws and regulations. 

BIG registration 

The BIG registration (Beroepen in de Individuele Gezondheidszorg) is a statutory, online, and public register. A BIG registration explains what you can and cannot do as a healthcare provider (for example, performing a specific surgical procedure or administering injections). The BIG Act is designed to protect patients from incompetent healthcare providers (who do not have the requisite qualifications). The required BIG registration applies to, among other occupations, doctors, pharmacists, physiotherapists, healthcare psychologists, psychotherapists, dentists, general remedial educationalists, physician assistants, OB-GYNs, and nurses. You are only permitted to hold these occupations if you are listed in the BIG register. Healthcare providers in the BOG register must re-register every five years. 

If you are a BIG-registered healthcare provider, you must actively announce your BIG number. You must list the number in all places where you display your name and occupation for professional purposes, including your website (or your clients’ website), emails, and invoices. This makes it easier for patients to check whether you are listed in the register as a healthcare provider. 

Experimental occupations 

A number of occupations known as experimenteerberoepen (experimental occupations) are included in the BIG register for a limited period of time (5 years). During the experimental period, these occupations will have independent powers, will be monitored, and an evaluation survey will be conducted. Since 2019, the Bachelor’s degree in Medical Services has been included in the BIG register. Registered Dental Hygienist was added to the list on 1 July 2020. 

Wkkgz Act 

The Dutch government seeks to ensure that everyone in the Netherlands receives good-quality healthcare, and has enshrined in law what constitutes ‘quality healthcare’. It also prescribes what should happen whenever people have complaints about the health services they receive. This is provided for in the Wet kwaliteit, klachten en geschillen zorg (Quality, Complaints, and Disputes Act/Wkkgz). This act applies to all healthcare providers. There are two ways for independent contractors to fulfil the requirements under the Quality, Complaints and Disputes Act (Wkkgz): 

1. You have clients of your own, and the client has hired you directly. In this case, you are personally responsible for ensuring that you fulfil the requirements under the Quality, Complaints, and Disputes Act/Wkkgz. 

1. You are a client of several different healthcare providers. In this case, the written agreement you sign with your client must provide for how you both satisfy the requirements under the Quality, Complaints, and Disputes Act/Wkkgz. 

The Verklaring omtrent gedrag (Certificate of Good Conduct/VOG) falls under the remit of the Quality, Complaints, and Disputes Act/Wkkgz. This leaflet (in Dutch) will tell you whether you are required to comply with the Act. 

Wtza legislation 

The new Wtza (Care Providers [Accreditation] Act has replaced the Healthcare Institutions Accreditation Act (Wtzi) in 2022. The act is divided into three sections: 

• disclosure requirement (in Dutch) 

• permit requirement (in Dutch) 

• the requirement of an independent internal regulator (in Dutch) 

All new healthcare providers who come under the remit of the Wkkgz are required to report to the Inspectie voor de Gezondheidszorg (Healthcare Inspectorate) before they can start providing care.  

Wet zorg en dwang (Care and Coercion Act) 

The Wet zorg en dwang (Care and Coercion Act/Wzd, in Dutch) is designed to protect clients who have been diagnosed with dementia or who have learning disabilities from the harmful effects of involuntary care. People with dementia or learning disabilities should receive care on a voluntary basis as much as possible. If there are no alternatives available, the care provider must follow the Wzd Roadmap (in Dutch). The Act applies to organisations and individual care providers (independent contractors) and applies to care provided within institutions, at home or in small-scale residential facilities and day-care centres. 

If you, as an independent contractor, provide involuntary care as a care provider and are subject to the Wkkgz, you hold responsibility under the Wzd. In addition to the Wzd roadmap, you must also register with the location register (in Dutch). You must register using the address listed in the KVK Business Register. Registration is essential in order to act diligently and assess the measure. 

AGB Code 

You require a personal Algemeen GegevensBeheer-code (AGB code, in Dutch) – a national code by which care providers must be identified – in order to report the care provided. You can only request an AGB code if you have a valid BIG registration and/or a registration with a professional association or quality register. When applying for an AGB code for your business, you always require a listing in the KVK Business RegisterBR. The AGB register is managed by Vektis, a business intelligence centre for the healthcare sector. 

Medical file 

As a care provider, you are required to maintain and update a medical file of all your patients. This file contains data regarding, among other things, the patient’s health and the nature of your treatment. 

Since 1 July 2020, you are required to offer your patients the option to view and manage their data electronically. 

Insured care 

If you intend to provide your clients with insured care (this refers to care insured under the Zorgverzekeringswet (Health Insurance Act) and the Wet langdurige zorg (Long-Term Care Act), there are several ways of doing this. This guarantees you are paid for the care services you provide and that the care the patient receives is covered by their insurance (at least in part). 

GDPR (General Data Protection Regulation) 

The General Data Protection Regulation (GDPR_BR) applies to all businesses that process personal data, including independent healthcare contractors. You must manage patients’ sensitive personal data (in Dutch) with care. It makes no difference whether the data is processed manually or by a computer. ‘Processing personal data’ means, among other things: collecting, recording, storing, using, forwarding, disseminating, providing, and aggregating data. 

Taxes

VAT exemption 

The VAT exemption (in Dutch) applies only to the personal medical care of people. This is the case if the treatments are intended to protect, maintain, or restore the patient’s health. VAT exemption means that you, as a care provider, do not charge VAT to your client, but that you are also not eligible to claim back VAT. 

VAT and healthcare recruitment agencies 

There are several ways in which you can work for a healthcare institution as an independent contractor. This could potentially cause confusion about whether or not you are required to pay VAT as an independent contractor. The majority of independent healthcare contractors/providers are not subject to VAT. The main criterion is how you perform the work: either through an agency or directly for the healthcare provider. If you are employed through an agency, you may be required to charge VAT to the agency. 

There are two ways of working through an agency: 

• You work directly for the healthcare institution through an agency. The agency has matched you with the healthcare institution and has recorded this in an agency contract. You will then bill the healthcare institution directly, without charging VAT. In this case, the agency is not officially a party to the agreement. Your independence as an independent contractor is better protected in this case, as you will likely work for multiple clients. 

• You work for the agency based on a contract for services (opdrachtovereenkomst) and bill the agency directly, rather than the healthcare provider. In this case, you will be required to charge the agency VAT. Note that you will need to personally apply for your VAT number with the Dutch tax authorities. You can do this by completing the ‘Opgaaf Startende onderneming’ (‘New Business Declaration’, in Dutch) form. You must add the following note on the form: btw-belastbare diensten via een bemiddelingsbureau (‘VAT-taxable services provided through a healthcare recruitment agency’).[Einde van tekstterugloop]Bear in mind that working in this manner could potentially undermine your independence, because if you work exclusively for the agency, you have only one client. This could potentially lead to false self-employment. 

Avoiding false self-employment 

The Dutch tax authorities determine whether you are classified as a business owner for the purpose of income tax and will then check if you are an independent business owner/healthcare professional. This would be organised under the DBA Act, but the DBA will not be enforced until 1 January 2021. However, this does not mean you can simply disregard the act. The tax authorities began shifting their focus more to clients in October 2019, and on 4 February 2020 the State Secretary for Finance, Hans Vijlbrief, announced that the healthcare sector and several other sectors and industries will be prioritised. This includes hospitals, independent clinics, recruitment agencies, and intermediaries operating in the healthcare sector. This sector-based approach means that the tax authorities intend to work with the industry associations or umbrella organisations to ensure compliance.[Einde van tekstterugloop]Independent contractors and their clients are responsible for the relationship they enter into with each other. It all revolves around the question: “Are you an independent contractor or in paid employment?” Are you in doubt? Avoid false self-employment and use a model agreement issued by the tax authorities in order to be sure that you are not in paid employment. 

Quality mark 

As an independent healthcare contractor, you can apply for a quality mark. A quality mark means you do not have to demonstrate that you meet all the applicable requirements. It is a proof of quality through which you demonstrate that you handle your position as an independent business owner in a professional manner, while at the same time reassuring your clients that you work in accordance with the rules and requirements. This includes the requirements under the Wkkgz. You are not required to use a quality mark, and you can personally decide whether a particular quality mark is right for you. There are two issuers of quality marks in the healthcare sector: 

• Mijn Keurmerk by Kiwa for independent healthcare contractors (in Dutch). 

• HKZ-keurmerk for independent healthcare and welfare contractors (in Dutch). 

How do you find clients? 

There are different ways of finding clients, including both private individuals and healthcare institutions. You can set out to find clients on your own, for example, through your personal network (in Dutch) and through online platforms where supply meets demand. Alternatively, you can also use the services of a recruitment agency if you have trouble selling yourself and finding new clients. If you want to make it easy for people to find your business online, you can use online marketing to ensure that you reach new clients online and can achieve your goal of growing your business. 

Tips 

1. Sector organisations 

If you have any questions about working as an independent healthcare contractor, you can contact various sector organisations for the healthcare sector (scroll down to 'Find your sector organisation’ and select Care providers). 

2. Cooperation 

There are a lot of benefits to working together, including sharing expenses and covering for each other if you are sick or unavailable. In addition, it is easier to take on larger projects and acquire new knowledge. Cooperation calls for effective preparation, including finding a reliable partner and setting down some ground rules together. 

3. Business ownership 

Ranging from hourly rates to insurance and from picking a business name to managing your accounts, the Getting started checklist will help you run your business.