The 2026 healthcare procurement season has begun. Healthcare insurers published their procurement policies on 1 April 2025. So what awaits healthcare providers this year? Staff shortages and an ageing population are straining access to care. Waiting lists are as long as ever and access to care is under increasing pressure. Meanwhile, the costs for healthcare providers continue to rise, partly due to new collective labour agreements. But the threat of escalating trade wars and inflation is also creating a great deal of uncertainty. Healthcare buyers and the Ministry of Health, Welfare and Sport continue to discourage uncontracted work by healthcare providers. In short, these are turbulent times for healthcare providers. It is therefore essential to obtain sound (multi-year) contracts from healthcare insurers with adequate indexations.
STAR judgment
The Court of Appeal of The Hague issued the STAR judgment last year. It ruled, among other things, that (i) healthcare insurer Zilveren Kruis (ZK) had to index-link the rates to cover the increased payroll and equipment costs; and (ii) cross-financing within a healthcare organisation may not be regarded as a solution for non-cost-covering healthcare insurance rates. The judgment caused quite a stir and healthcare providers have not been sitting by idly since. The STAR judgment was followed by various proceedings in which healthcare providers successfully took action against healthcare insurance contracts with inadequate rates. Three recent cases are addressed in this blog. We explain how healthcare providers can benefit from the STAR judgment and the subsequent cases. Eight concrete tips are provided in that context.
Case 1: orthopaedic shoemakers and ZK
On 9 April 2025, the District Court of The Hague ruled in a case brought by several providers of orthopaedic shoes against healthcare insurer ZK. In late 2024, citing the STAR judgment, the shoemakers had already succeeded in enforcing a substantial rate increase by CZ and earlier in the summer of 2024 also by VGZ. ZK had made the orthopaedic footwear providers a contract offer for 2025. It had insufficiently indexed its rates for years. A large group of providers then took ZK to court.
According to the court, healthcare providers are dependent on ZK. Not only is ZK the largest healthcare insurer in the Netherlands, but working uncontracted is not easy in practice. The NZa’s Contracting Guidelines state that the OVA (Government Contributions for Labour Cost Development in Healthcare) is the starting point in the wage indexation negotiations. According to the court, the Guidelines are “rules of thumb that serve as a guide in the contracting between healthcare insurers and healthcare providers, to which they conform, in principle”. ZK may deviate from the Guidelines, but must give proper reasons for doing so, which it had failed to do.
The court set store by the fact that many providers signed the ZK contract under protest. It ruled that ZK (i) had to better justify its rates and (ii) had to cancel its efficiency markdown, because it had failed to provide sufficient reasons for the markdown. According to the court, ZK has a “special responsibility to adequately substantiate deviations from the above-mentioned rules of thumb and to explain on the basis of which assumptions it arrived at its price offer, as far as that offer deviates from customary indexations.”
ZK must now better justify its rates. In doing so, it must check whether its rates are realistic, taking into account the cost price study put forward by the healthcare providers. ZK must specifically respond to the providers’ cost price study. The court also pointed out to ZK that it must properly justify its rates not only now, but also in the future, especially if providers object to them. The best way for ZK to do so is with industry associations of healthcare providers. An appeal filed by the healthcare providers against this ruling is currently pending.
Case 2: Medipoint et al. and CZ
Medipoint is a supplier of various types of aids. It had entered into several multi-year contracts with healthcare insurer CZ to supply aids to patients. The rates in these contracts had not or had hardly been indexed for years, despite repeated requests from care providers to do so. Medipoint felt that these rates were no longer realistic and therefore instituted preliminary relief proceedings against CZ. Several care providers successfully intervened in these proceedings.
In the run-up to the hearing, CZ had made an offer to Medipoint to conduct a cost price study of its medical aids contracts. CZ had not previously carried out such a study. It promised to adjust its rates retroactively if the study was reason to do so. CZ also stated that its study would be completed before the start of the 2026 healthcare procurement, so that the outcomes could be taken into account in the 2026 rates. Until the outcomes of the study were known, CZ proposed already implementing a provisional indexation in the aids contracts. The District Court of Zeeland-West Brabant ruled in the preliminary relief proceedings on 19 March 2025 that a cost price study is “in principle, an appropriate means of settling a dispute regarding rates if all the parties involved are given the opportunity to provide input and a reasonable degree of objectivity is guaranteed.” The court also stressed that “the pursuit of cost efficiency must at all times be balanced with the ability to provide good, appropriate care.” In its ruling, the court specified the minimum requirements that the cost price study must meet. It also explained that CZ cannot argue in retrospect that the healthcare providers did not make certain savings; those targets must be set in advance (and not afterwards).
Case 3: respiratory aids providers and ONVZ
Healthcare insurer ONVZ offered providers of respiratory aids a non-negotiable contract in 2024 with a term of one year. The 2025 rates that ONVZ offered had dropped (sharply) or remained the same as the 2024 rates (despite cost increases). ONVZ set those rates entirely unilaterally. It thereby relied on a study by Gupta, which allegedly showed that ONVZ was overpaying for the care in question. ONVZ had commissioned the Gupta report without the healthcare providers or industry associations being consulted. The providers were never given access to the Gupta report – even when they requested it. After the healthcare providers had unsuccessfully requested ONVZ to consult on the contract signed under protest, they instituted preliminary relief proceedings against ONVZ. The District Court of Midden-Nederland ruled in those proceedings on 10 April 2025.
The court found that, even though ONVZ’s national market share is limited (at 2.3%), healthcare providers are dependent on ONVZ. This is partly due to the fact that, although uncontracted work is an option in theory, in practice it is not (for instance due to a lack of referrals and to the administrative burden). The court then ruled that ONVZ should not have been allowed to simply lower its rates without consulting with healthcare providers: “This means that ONVZ may not simply set its rates below the cost price of the medical aids providers without consultation or answers to questions from those aids providers. The fact that it believes that its rates are indeed reasonable and verifiable because they are based on the market average is therefore irrelevant. At the very least, ONVZ should have entered into consultations on this point and, through those consultations, must take sufficient account of the interests of the aids providers.”
The court also took into account the fact that healthcare insurers wish to adopt their competitors’ aim for ever lower rates; known as the race to the bottom. The care providers had submitted operating budgets, comparisons with other healthcare insurers’ rates, and cost prices to demonstrate that ONVZ’s rates were not cost-effective. ONVZ argued that it could not verify those figures, but the court did not subscribe to that argument: ONVZ was unwilling to enter into consultations with the healthcare providers, despite the fact that the healthcare providers had expressly requested this on various occasions. The court also set store by the fact that a significant part of the market had to work at rates that were too low because of ONVZ. It ultimately ruled that ONVZ had to increase its rates for four products. The court also ruled that, as the providers had requested, ONVZ was not allowed to use its Gupta report for the 2026 healthcare procurement.
Lessons learned
As soon as rates are demonstrably no longer realistic and cost-effective and/or administrative burdens increase without reason, healthcare providers may call healthcare insurers to account. The recurrent theme in the STAR judgment and subsequent case law is that courts are increasingly critical of (i) the way healthcare insurers procure care (often in breach of the NZa rules) and (ii) the rates (with markdowns and/or without indexations) that they charge. In light of the above, we have the following eight tips for healthcare providers :
- Point out to the healthcare insurer that it is must at all times charge realistic rates. This also applies to contracts already entered into – also if they do not include an indexation clause.
- If healthcare insurers apply markdowns that are not or are insufficiently justified, point out to the healthcare insurer that this is prohibited on the grounds of mandatory NZa healthcare procurement rules. Inform the healthcare insurer that the NZa also enforces those rules. The NZa issued a warning to VGZ in 2024, for instance. It is furthermore finalising decision-making in enforcement requests against ASR, ONVZ, and Salland.
- Request the healthcare buyer to engage with you and/or, for the sake of procedural efficiency, your industry association on the contract. If the healthcare insurer dismisses your objections or refuses refuse to engage in talks, object and carefully document your objections.
- If you believe that the rates offered by the healthcare insurer are unrealistic, immediately point this out to the healthcare insurer in writing. Submit as much (written) substantiation as possible as to why the rates are unrealistic or are not cost-effective, e.g. in the form of e-mails and letters from suppliers in which they (repeatedly) raise their prices. Make it clear that the healthcare insurer’s rates lag behind the objective NZa price index figures, also, for instance, in the form of an operating budget. Accurate cost price and other calculations may also be very important in that context. Where necessary, engage a third party to perform and/or check calculations and share these with the healthcare buyer in good time.
- If the healthcare insurer agrees to perform a cost price study to correct the rates if necessary, it is important that it carefully consider the input of an adequate number of care providers in good time. Be alert to this and call the healthcare insurer to account in good time if this process is not proceeding as it should.
- If the healthcare insurer is unwilling to adjust the contract (or to do so sufficiently), but you have no other option than to sign the contract, sign under express written protest while requesting immediately consultation with you in order to arrive at realistic rates.
- If you decide (after point 6 or otherwise) to take legal action against a contract, it is possible for other healthcare providers to join these proceedings. It is important in that regard that competition law be observed at all times. Seek legal advice in good time.
See this blog and this briefing for more tips on the rights of healthcare providers and the duties of healthcare insurers in the 2026 healthcare insurance contracting. More information on the rights of healthcare providers and their professional and/or industry associations, and the duties of healthcare purchasers in healthcare contracting, can also be found at www.zorgcontractering.com.
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