The impact on these firms is much bigger than in the Big 4 where a sanction or loss of one partner, even for a large ugly fraud is diluted by the sheer numbers of partners who can step up in his or her place.

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Critics in Congress have said they would like to see much bigger numbers coming from the detection system given the sheer size of the Medicare program, which by some estimates costs taxpayers tens of billions of dollars a year in fraud.

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