Background: The first calculation of the Diagnosis Related Groups (DRGs) in Germany resulted in a drastic reduction of reimbursements for liver transplantations (LTX). While under the previous reimbursement system, a liver transplantation was calculated with approximately € 125.000, the newly introduced German DRG system calculated for a liver transplantation without complications for 2004 a case weight of 11,9 and hence, based on the base rate utilized a fee of € 35.000 - € 45.000. Since under these circumstances the financing for clinical liver transplantations seemed to be in jeopardy, the Deutsche Transplantationsgesellschaft (German Society for Organ Transplantation) conducted an evaluation of the actual costs of liver transplantations. Materials and Methods: The data of 75 transplant admissions from five major transplant centres were collected and 177 cost parameters were captured each day. In addition, the data which is important for the classification of the DRGs (diagnosis, procedures, length of hospital stay and duration of ventilation) were recorded and cost comparisons for single parameters were performed using the DKG-NT (Deutsche Krankenhausgesellschaft Normal-Tarif [German hospital association regular price]) and Lauer-Tax (drugstore base buying price). With this method the total actual costs per case were determined and also which parameter could be useful as a cost separator. Results: Based on our data, our estimated cost for the DRG liver transplantation was much higher then the actual reimbursement under the new German DRG system. This led us to initiate a discussion with the InEK and subsequently the introduction of weighed hospital days for better allocation of the cost to the liver transplanted patient. Furthermore, based on our findings, additional split criteria were discussed with the InEK, which partially have been included into the DRG 2005 system. Conclusions: The investigation which was performed in cooperation with the InEK underlined that the actual reimbursement for liver transplantations does not mirror the actual cost, and the introduction of new cost separators, new ICD and procedure codes should enable the hospitals in the future to allocate the real cost of liver transplantations to the liver recipient. The changes already implemented have resulted in a significantly higher reimbursement for liver transplantation for 2005, and have reduced the financial gap for liver transplantations considerably.