Malingering is the intentional production of false or grossly exaggerated symptoms motivated by internal and external incentives. The true incidence of malingering in the emergency department is unknown because of the difficulty of identifying whether patients are fabricating their symptoms. Malingering is considered a diagnosis of exclusion; a differential diagnosis framework is described to guide emergency physicians. Several case studies are presented and analyzed from a medical ethics perspective. Practical recommendations include use of the NEAL (neutral, empathetic, and avoid labeling) strategy when caring for patients suspected of malingering.